Adults

Esomeprazole magnesium for delayed-release oral suspension is indicated for the short-term treatment (4 to 8 weeks) in the healing and symptomatic resolution of diagnostically confirmed EE in adults. For those patients who have not healed after 4 to 8 weeks of treatment, an additional 4- to 8- week course of esomeprazole magnesium may be considered.

Pediatric Patients 12 Years to 17 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for the short-term treatment (4 to 8 weeks) for the healing of EE in pediatric patients 12 years to 17 years of age.

Pediatric Patients 1 Year to 11 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for the short-term treatment (8 weeks) for the healing of EE in pediatric patients 1 year to 11 years of age.

Pediatric Patients 1 Month to Less Than 1 Year of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (up to 6 weeks) of EE due to acid-mediated GERD in pediatric patients 1 month to less than 1 year of age.

Esomeprazole magnesium for delayed-release oral suspension is indicated for the maintenance of healing of EE in adults. Controlled studies do not extend beyond 6 months.

Adults

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (4 to 8 weeks) of heartburn and other symptoms associated with GERD in adults.

Pediatric Patients 12 Years to 17 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (4 weeks) of heartburn and other symptoms associated with GERD in pediatric patients 12 years to 17 years of age.

Pediatric Patients 1 Year to 11 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (up to 8 weeks) of heartburn and other symptoms associated with GERD in pediatric patients 1 year to 11 years of age.

Esomeprazole magnesium for delayed-release oral suspension is indicated for the reduction in the occurrence of gastric ulcers associated with continuous NSAID therapy in adult patients at risk for developing gastric ulcers. Patients are considered to be at risk due to their age (60 years and older) and/or documented history of gastric ulcers. Controlled studies do not extend beyond 6 months.

Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

Triple Therapy

Esomeprazole magnesium for delayed-release oral suspension in combination with amoxicillin and clarithromycin is indicated for the treatment of adult patients with H. pylori infection and duodenal ulcer disease (active or history of within the past 5 years) to eradicate H. pylori.

In patients who fail therapy, susceptibility testing should be done. If resistance to clarithromycin is demonstrated or susceptibility testing is not possible, alternative antimicrobial therapy should be instituted [see Clinical Pharmacology (12.4) and the prescribing information for clarithromycin].

Esomeprazole magnesium for delayed-release oral suspension is indicated for the long-term treatment of pathological hypersecretory conditions, including Zollinger-Ellison Syndrome, in adults.

Table 1 shows the recommended adult dosage of esomeprazole magnesium by indication.

The duration of esomeprazole magnesium treatment should be based on available safety and efficacy data specific to the defined indication and dosing frequency and individual patient medical needs. Esomeprazole magnesium should only be initiated and continued if the benefits outweigh the risks of treatment.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 1: Recommended Dosage of Esomeprazole Magnesium in Adults by Indication</span> </caption> <colgroup> <col width="34.86%"/> <col width="32.1%"/> <col width="33.04%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle"><span class="Bold">Adult Indication</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Recommended Dosage of Esomeprazole magnesium for delayed-release oral suspension</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Treatment Duration</span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="middle">Healing of EE <br/> </td><td class="Rrule" valign="middle">20 mg or 40 mg<span class="Sup">1</span> once daily <br/> </td><td align="justify" class="Rrule" valign="middle">4 to 8 weeks<span class="Sup">2 </span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="middle">Maintenance of Healing of EE <br/> </td><td class="Rrule" valign="middle">20 mg once daily <br/> </td><td align="justify" class="Rrule" valign="middle">Controlled studies do not extend beyond 6 months <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="middle">Treatment of Symptomatic GERD <br/> </td><td class="Rrule" valign="middle">20 mg once daily <br/> </td><td align="justify" class="Rrule" valign="middle">4 weeks; if symptoms do not resolve completely, consider an additional 4 weeks <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="middle">Risk Reduction of NSAID-Associated Gastric Ulcer <br/> </td><td class="Rrule" valign="middle">20 mg or 40 mg<span class="Sup">1</span> once daily <br/> </td><td align="justify" class="Rrule" valign="middle">Controlled studies do not extend beyond 6 months <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" rowspan="3" valign="middle"><span class="Italics">H. pylori </span>Eradication to Reduce the Risk of Duodenal Ulcer Recurrence (Triple Therapy) <br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 40 mg once daily<span class="Sup">1</span> <br/> </td><td class="Rrule" valign="middle">10 days <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Amoxicillin 1000 mg twice daily<span class="Sup">3</span> <br/> </td><td class="Rrule" valign="middle">10 days <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Clarithromycin 500 mg twice daily<span class="Sup">3 </span> <br/> </td><td class="Rrule" valign="middle">10 days <br/> </td> </tr> <tr class="Last"> <td align="justify" class="Lrule Rrule" valign="middle">Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome <br/> </td><td align="justify" class="Rrule" valign="middle">Starting dosage is 40 mg twice daily<span class="Sup">4</span>; individualize the regimen to patient needs. <br/> <br/>Dosages of up to 240 mg/day have been administered <span class="Italics">[see <a href="#Section_14.7">Clinical Studies (14.7)</a>]</span><span class="Italics">.</span> <br/> </td><td align="center" class="Rrule" valign="middle">As long as clinically indicated <br/> </td> </tr> </tbody> </table></div>

1. A maximum dosage of 20 mg once daily is recommended for patients with severe liver impairment (Child-Pugh Class C) [see Use in Specific Populations (8.6)]. 2. Most patients are healed within 4 to 8 weeks. For patients who do not heal after 4 to 8 weeks, an additional 4 to 8 weeks of treatment may be required to achieve healing [see Clinical Studies (14.1)]. 3. Refer to the amoxicillin and clarithromycin prescribing information for dosage adjustments in elderly and renally-impaired patients. 4. A starting dosage of 20 mg twice daily is recommended for patients with severe liver impairment (Child-Pugh Class C) [see Use in Specific Populations (8.6)].

Table 2 shows the recommended dosage of esomeprazole magnesium in pediatric patients by indication.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="97%"> <caption> <span>Table 2: Recommended Dosage of Esomeprazole Magnesium in Pediatric Patients by Indication</span> </caption> <colgroup> <col width="18.92%"/> <col width="24.86%"/> <col width="31.66%"/> <col width="24.56%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Indication</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Patient Age</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Recommended Dosage</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Duration</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle">Healing of EE<br/> </td><td class="Rrule" valign="middle">12 years to 17 years <br/> </td><td align="justify" class="Rrule" valign="top">Esomeprazole magnesium for delayed-release oral suspension: <br/> 20 mg or 40 mg once daily <br/> </td><td class="Rrule" valign="top">4 to 8 Weeks <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">1 year to 11 years<span class="Sup">1 </span> <br/> </td><td class="Rrule" valign="top">Esomeprazole magnesium for delayed-release oral suspension:<br/> <br/> <span class="Underline">Less than 20 kg </span> <br/>10 mg once daily <br/> <br/> <span class="Underline">20 kg and greater</span> <br/>10 mg or 20 mg once daily <br/> </td><td class="Rrule" valign="top">8 weeks <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="middle">Treatment of EE due to Acid-Mediated GERD<br/> </td><td class="Rrule" valign="middle">1 month to less than 1 year<span class="Sup">2</span> <br/> </td><td class="Rrule" valign="top">Esomeprazole magnesium for delayed-release oral suspension:<br/> <br/> <span class="Underline">3 kg to 5 kg </span> <br/>2.5 mg once daily <br/> <br/> <span class="Underline">Greater than 5 kg to 7.5 kg </span> <br/>5 mg once daily <br/> <br/> <span class="Underline">Greater than 7.5 kg to 12 kg</span> <br/>10 mg once daily <br/> <br/> </td><td class="Rrule" valign="top">Up to 6 weeks <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" rowspan="2" valign="middle">Treatment of Symptomatic GERD<br/> </td><td class="Rrule" valign="middle">12 years to 17 years<br/> </td><td align="justify" class="Rrule" valign="top">Esomeprazole magnesium for delayed-release oral suspension: 20 mg once daily <br/> </td><td class="Rrule" valign="top">4 weeks <br/> <br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">1 year to 11 years <br/> </td><td align="justify" class="Rrule" valign="top">Esomeprazole magnesium for delayed-release oral suspension:<br/> 10 mg once daily<span class="Sup">1</span> <br/> </td><td class="Rrule" valign="top">Up to 8 weeks <br/> <br/> </td> </tr> </tbody> </table></div>

1 Dosages over 1 mg/kg/day have not been studied

2 Dosages over 1.33 mg/kg/day have not been studied

Esomeprazole Magnesium For Delayed-Release Oral Suspension

Administer esomeprazole magnesium for delayed-release oral suspension orally or via a nasogastric or gastric tube, as described below.

       Oral Administration

       Administration via Nasogastric or Gastric Tube

Esomeprazole Magnesium For Delayed-Release Oral Suspension

{ "type": "p", "children": [], "text": "\nEsomeprazole Magnesium For Delayed-Release Oral Suspension\n" }

{ "type": "ul", "children": [ "10 mg esomeprazole in a unit dose packet containing a fine yellow powder, consisting of white to off white spherical esomeprazole delayed-release granules and pale yellow inactive granules. " ], "text": "" }

{ "type": "ul", "children": [ "Esomeprazole magnesium is contraindicated in patients with known hypersensitivity to substituted benzimidazoles or to any component of the formulation. Hypersensitivity reactions may include anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute tubulointerstitial nephritis, and urticaria [see Warnings and Precautions (5.2), Adverse Reactions (6.2)]. \n", "For information about contraindications of amoxicillin and clarithromycin, indicated in combination with esomeprazole magnesium for H. pylori eradication to reduce the risk of duodenal ulcer recurrence, refer to the Contraindications section of the respective prescribing information. ", "Proton pump inhibitors (PPIs), including esomeprazole magnesium, are contraindicated in patients receiving rilpivirine-containing products [see Drug Interactions (7)]. \n" ], "text": "" }

In adults, symptomatic response to therapy with esomeprazole magnesium does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI. In older patients, also consider an endoscopy.

Acute tubulointerstitial nephritis (TIN) has been observed in patients taking PPIs and may occur at any point during PPI therapy. Patients may present with varying signs and symptoms from symptomatic hypersensitivity reactions to non-specific symptoms of decreased renal function (e.g., malaise, nausea, anorexia). In reported case series, some patients were diagnosed on biopsy and in the absence of extra-renal manifestations (e.g., fever, rash or arthralgia). Discontinue esomeprazole magnesium and evaluate patients with suspected acute TIN [see Contraindications (4)].

Published observational studies suggest that PPI therapy like esomeprazole magnesium may be associated with an increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve [see Adverse Reactions (6.2)].

Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents. For more information specific to antibacterial agents (clarithromycin and amoxicillin) indicated for use in combination with esomeprazole magnesium, refer to Warnings and Precautions section of the corresponding prescribing information.

Several published observational studies suggest that proton pump inhibitor (PPI) therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines [see Dosage and Administration (2) and Adverse Reactions (6.2)].

Severe cutaneous adverse reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) have been reported in association with the use of PPIs [see Adverse Reactions (6.2)]. Discontinue esomeprazole magnesium at the first signs or symptoms of severe cutaneous adverse reactions or other signs of hypersensitivity and consider further evaluation.

Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE) have been reported in patients taking PPIs, including esomeprazole. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematosus cases were CLE.

The most common form of CLE reported in patients treated with PPIs was subacute CLE (SCLE) and occurred within weeks to years after continuous drug therapy in patients ranging from infants to the elderly. Generally, histological findings were observed without organ involvement.

Systemic lupus erythematosus (SLE) is less commonly reported than CLE in patients receiving PPIs. PPI associated SLE is usually milder than non-drug induced SLE. Onset of SLE typically occurred within days to years after initiating treatment primarily in patients ranging from young adults to the elderly. The majority of patients presented with rash; however, arthralgia and cytopenia were also reported.

Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving esomeprazole magnesium, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks. Serological testing (e.g., ANA) may be positive and elevated serological test results may take longer to resolve than clinical manifestations.

Avoid concomitant use of esomeprazole magnesium with clopidogrel. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as esomeprazole, that inhibit CYP2C19 activity. Concomitant use of clopidogrel with 40 mg esomeprazole reduces the pharmacological activity of clopidogrel. When using esomeprazole magnesium consider alternative anti-platelet therapy [see Drug Interactions (7)].

Daily treatment with any acid-suppressing medications over a long period of time (e.g., longer than 3 years) may lead to malabsorption of cyanocobalamin (vitamin B-12) caused by hypo- or achlorhydria. Rare reports of cyanocobalamin deficiency occurring with acid-suppressing therapy have been reported in the literature. This diagnosis should be considered if clinical symptoms consistent with cyanocobalamin deficiency are observed.

Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. Hypomagnesemia may lead to hypocalcemia and/or hypokalemia and may exacerbate underlying hypocalcemia in at-risk patients. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI.

For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically [see Adverse Reactions (6.2)].

Consider monitoring magnesium and calcium levels prior to initiation of esomeprazole magnesium and periodically while on treatment in patients with a preexisting risk of hypocalcemia (e.g., hypoparathyroidism). Supplement with magnesium and/or calcium, as necessary. If hypocalcemia is refractory to treatment, consider discontinuing the PPI.

Drugs which induce CYP2C19 or CYP3A4 (such as St. John’s Wort or rifampin) can substantially decrease esomeprazole concentrations [see Drug Interactions (7)]. Avoid concomitant use of esomeprazole magnesium with St. John’s Wort or rifampin.

Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors. Healthcare providers should temporarily stop esomeprazole treatment at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g., for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary [see Clinical Pharmacology (12.2)].

Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration a temporary withdrawal of the PPI may be considered in some patients [see Drug Interactions (7)].

PPI use is associated with an increased risk of fundic gland polyps that increases with long-term use, especially beyond one year. Most PPI users who developed fundic gland polyps were asymptomatic and fundic gland polyps were identified incidentally on endoscopy. Use the shortest duration of PPI therapy appropriate to the condition being treated.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Adults

The safety of NEXIUM delayed-release capsules was evaluated in over 15,000 patients (aged 18 to 84 years) in clinical trials worldwide including over 8,500 patients in the United States and over 6,500 patients in Europe and Canada. Over 2,900 patients were treated in long-term studies for up to 6 to 12 months.

The safety in the treatment of healing of EE in adults was assessed in four randomized comparative clinical trials, which included 1,240 patients who received NEXIUM 20 mg once daily, 2,434 patients on NEXIUM 40 mg once daily, and 3,008 patients on omeprazole 20 mg once daily. The most frequently occurring adverse reactions (at least 1%) in all three groups were headache (5.5%, 5%, and 3.8%, respectively) and diarrhea (no difference among the three groups). Nausea, flatulence, abdominal pain, constipation, and dry mouth occurred at similar rates among patients taking NEXIUM or omeprazole.

Less common adverse reactions with an incidence of less than 1% are listed below by body system:

Body as a Whole: abdomen enlarged, allergic reaction, asthenia, back pain, chest pain, substernal chest pain, facial edema, peripheral edema, hot flushes, fatigue, fever, flu-like disorder, generalized edema, leg edema, malaise, pain, rigors;

Cardiovascular: flushing, hypertension, tachycardia;

Endocrine: goiter;

Gastrointestinal: bowel irregularity, constipation aggravated, dyspepsia, dysphagia, dysplasia GI, epigastric pain, eructation, esophageal disorder, frequent stools, gastroenteritis, GI hemorrhage, GI symptoms not otherwise specified, hiccup, melena, mouth disorder, pharynx disorder, rectal disorder, serum gastrin increased, tongue disorder, tongue edema, ulcerative stomatitis, vomiting;

Hearing: earache, tinnitus;

Hematologic: anemia, anemia hypochromic, cervical lymphadenopathy, epistaxis, leukocytosis, leukopenia, thrombocytopenia;

Hepatic: bilirubinemia, hepatic function abnormal, SGOT increased, SGPT increased;

Metabolic/Nutritional: glycosuria, hyperuricemia, hyponatremia, increased alkaline phosphatase, thirst, vitamin B12 deficiency, weight increase, weight decrease;

Musculoskeletal: arthralgia, arthritis aggravated, arthropathy, cramps, fibromyalgia syndrome, hernia, polymyalgia rheumatica;

Nervous System/Psychiatric: anorexia, apathy, appetite increased, confusion, depression aggravated, dizziness, hypertonia, nervousness, hypoesthesia, impotence, insomnia, migraine, migraine aggravated, paresthesia, sleep disorder, somnolence, tremor, vertigo, visual field defect;

Reproductive: dysmenorrhea, menstrual disorder, vaginitis;

Respiratory: asthma aggravated, coughing, dyspnea, larynx edema, pharyngitis, rhinitis, sinusitis;

Skin and Appendages: acne, angioedema, dermatitis, pruritus, pruritus ani, rash, rash erythematous, rash maculo-papular, skin inflammation, sweating increased, urticaria;

Special Senses: otitis media, parosmia, taste loss, taste perversion;

Urogenital: abnormal urine, albuminuria, cystitis, dysuria, fungal infection, hematuria, micturition frequency, moniliasis, genital moniliasis, polyuria;

Visual: conjunctivitis, vision abnormal.

The following potentially clinically significant laboratory changes in clinical trials, irrespective of relationship to NEXIUM, were reported in 1% or less of patients: increased creatinine, uric acid, total bilirubin, alkaline phosphatase, ALT, AST, hemoglobin, white blood cell count, platelets, serum gastrin, potassium, sodium, thyroxine and thyroid stimulating hormone [see Clinical Pharmacology (12.2)]. Decreases were seen in hemoglobin, white blood cell count, platelets, potassium, sodium, and thyroxine.

Endoscopic findings that were reported as adverse reactions include: duodenitis, esophagitis, esophageal stricture, esophageal ulceration, esophageal varices, gastric ulcer, gastritis, hernia, benign polyps or nodules, Barrett’s esophagus, and mucosal discoloration.

The incidence of adverse reactions during 6-month trials for the maintenance of healing of EE with NEXIUM 20 mg once daily was similar to placebo. There were no differences in types of adverse reactions seen during maintenance treatment up to 12 months compared to short-term treatment.

Two placebo-controlled studies were conducted in 710 adult patients for the treatment of symptomatic GERD. The most common adverse reactions that were reported were: diarrhea (4%), headache (4%), and abdominal pain (4%).

Combination Treatment with NEXIUM, Amoxicillin and Clarithromycin

In clinical trials of H. pylori eradication of to reduce duodenal ulcer recurrence, no additional adverse reactions specific to the combination of NEXIUM delayed-release capsules, amoxicillin and clarithromycin were observed and were similar to those observed with NEXIUM, amoxicillin, or clarithromycin alone. The most frequently reported adverse reactions for patients who received NEXIUM, amoxicillin and clarithromycin for 10 days were diarrhea (9%), taste perversion (4%), and abdominal pain (4%). No adverse reactions were observed at higher rates with NEXIUM, amoxicillin and clarithromycin than were observed with NEXIUM alone.

In clinical trials using of NEXIUM, amoxicillin and clarithromycin, no additional increased laboratory abnormalities particular to these drug combinations were observed.

For more information on adverse reactions and laboratory changes with amoxicillin or clarithromycin, refer to Adverse Reactions section of the respective prescribing information. Pediatrics

1 Year to 17 Years of Age

The safety of esomeprazole magnesium for delayed-release oral suspension was evaluated in 316 pediatric and adolescent patients aged 1 year to 17 years in four clinical trials for the treatment of symptomatic GERD [see Clinical Studies (14.3)]. In 109 pediatric patients aged 1 year to 11 years, the most frequently reported (at least 1%) treatment-related adverse reactions in these patients were diarrhea (3%), headache (2%) and somnolence (2%). In 149 pediatric patients aged 12 years to 17 years the most frequently reported adverse reactions (at least 2%) were headache (8%), abdominal pain (3%), diarrhea (2%), and nausea (2%).

1 Month to Less Than 1 Year of Age

The safety of esomeprazole magnesium was evaluated in 167 infants from 1 month to less than 1 year of age with GERD in three clinical trials [see Use in Specific Populations (8.4)]. In a study that included 43 pediatric patients, the most frequently reported adverse reactions (at least 5%) with esomeprazole magnesium were irritability and vomiting. In a study that included 98 pediatric patients, administered esomeprazole magnesium for up to 6 weeks (including 39 patients randomized to the withdrawal phase), reported adverse reactions were: abdominal pain (1%), regurgitation (1%), tachypnea (1%), and increased ALT (1%).

The following adverse reactions have been identified during post-approval use of esomeprazole. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reports are listed below by body system:

Blood and Lymphatic: agranulocytosis, pancytopenia;

Eye: blurred vision;

Gastrointestinal: pancreatitis; stomatitis; microscopic colitis; fundic gland polyps;

Hepatobiliary: hepatic failure, hepatitis with or without jaundice;

Immune System: anaphylactic reaction/shock; systemic lupus erythematosus;

Infections and Infestations: GI candidiasis; Clostridium difficile-associated diarrhea;

Metabolism and nutritional disorders: hypomagnesemia (may lead to hypocalcemia and/or hypokalemia) [see Warnings and Precautions (5.9)];

Musculoskeletal and Connective Tissue: muscular weakness, myalgia, bone fracture;

Nervous System: hepatic encephalopathy, taste disturbance;

Psychiatric: aggression, agitation, depression, hallucination;

Renal and Urinary: interstitial nephritis;

Reproductive System and Breast: gynecomastia, erectile dysfunction;

Respiratory, Thoracic, and Mediastinal: bronchospasm;

Skin and Subcutaneous Tissue: alopecia, erythema multiforme, hyperhidrosis, photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis (some fatal), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP), cutaneous lupus erythematosus.

Adverse reactions associated with omeprazole may also be expected to occur with esomeprazole. See the full prescribing information for omeprazole for complete safety information.

Tables 3 and 4 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them. Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs.

{ "type": "p", "children": [], "text": "Tables 3 and 4 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them.\n Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs." }

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 3: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics</span> </caption> <colgroup> <col width="28.6%"/> <col width="71.4%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" colspan="2" valign="top"> <br/> <span class="Bold">Antiretrovirals </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact:</span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known.<br/> <br/> <ul class="Disc"> <li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> </li> <li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)]</a>.</span> </li> <li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole. </li> </ul> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention:</span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> <span class="Underline">Rilpivirine-containing products</span><span class="Underline">:</span> Concomitant use with esomeprazole magnesium is contraindicated <span class="Italics">[see <a href="#Section_4">Contraindications (4)</a>]</span>. <br/> <br/> <span class="Underline">Atazanavir</span><span class="Underline">:</span> See prescribing information for atazanavir for dosing information. <br/> <br/> <span class="Underline">Nelfinavir</span><span class="Underline">:</span> Avoid concomitant use with esomeprazole magnesium. See prescribing information for nelfinavir. <br/> <br/> <span class="Underline">Saquinavir</span><span class="Underline">:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities. <br/> <br/> <span class="Underline">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"> <br/>  <span class="Bold">Warfarin</span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"> <br/> <span class="Bold">Methotrexate </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class="Italics">[see <a href="#Section_5.12">Warnings and Precautions (5.12)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> A temporary withdrawal of esomeprazole magnesium may be considered in some patients receiving high-dose methotrexate. <br/> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol) </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Clopidogrel </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]. </span> <br/> <br/> <br/>There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel.<br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics"> Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Avoid concomitant use with esomeprazole magnesium. Consider use of alternative anti-platelet therapy <span class="Italics">[see <a href="#Section_5.7">Warnings and Precautions (5.7)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Citalopram </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Increased exposure of citalopram leading to an increased risk of QT prolongation <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Cilostazol </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Digoxin </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Potential for increased exposure of digoxin <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin. <br/> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Combination Therapy with Clarithromycin and Amoxicillin </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td class="Rrule" valign="middle"> <br/> Concomitant administration of clarithromycin with other drugs can lead to serious adverse reactions, including potentially fatal arrhythmias, and are contraindicated.<br/> <br/>Amoxicillin also has drug interactions. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> See <span class="Italics">Contraindications, Warnings </span>and <span class="Italics">Precautions </span>in prescribing information for clarithromycin. <br/> <br/> <br/> <br/>See <span class="Italics">Drug Interactions </span>in prescribing information for amoxicillin. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole) </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole magnesium and MMF. Use esomeprazole magnesium with caution in transplant patients receiving MMF <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]</span>. <br/> <br/> <br/> <br/>See the prescribing information for other drugs dependent on gastric pH for absorption. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Tacrolimus </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class="Italics">. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Interactions with Investigations of Neuroendocrine Tumors </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class="Italics">[see <a href="#Section_5.11">Warnings and Precautions (5.11)</a>, <a href="#Section_12.2">Clinical Pharmacology (12.2)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> Discontinue esomeprazole magnesium at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Interaction with Secretin Stimulation Test </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma. <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Discontinue esomeprazole magnesium 4 weeks prior to testing <span class="Italics">[see <a href="#Section_12.2">Clinical Pharmacology (12.2)</a>] </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">False Positive Urine Tests for THC </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="middle"> <br/> There have been reports of false positive urine screening test for tetrahydrocannabinol (THC) in patients receiving PPIs. <br/> <br/> </td> </tr> <tr class="Last"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> An alternative confirmatory method should be considered to verify positive results. <br/> <br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\">\n<caption>\n<span>Table 3: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics</span>\n</caption>\n<colgroup>\n<col width=\"28.6%\"/>\n<col width=\"71.4%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\">\n<br/> <span class=\"Bold\">Antiretrovirals </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact:</span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known.<br/> <br/>\n<ul class=\"Disc\">\n<li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n</li>\n<li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)]</a>.</span>\n</li>\n<li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole. </li>\n</ul> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention:</span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> <span class=\"Underline\">Rilpivirine-containing products</span><span class=\"Underline\">:</span> Concomitant use with esomeprazole magnesium is contraindicated <span class=\"Italics\">[see <a href=\"#Section_4\">Contraindications (4)</a>]</span>. <br/> <br/>\n<span class=\"Underline\">Atazanavir</span><span class=\"Underline\">:</span> See prescribing information for atazanavir for dosing information. <br/> <br/>\n<span class=\"Underline\">Nelfinavir</span><span class=\"Underline\">:</span> Avoid concomitant use with esomeprazole magnesium. See prescribing information for nelfinavir. <br/> <br/>\n<span class=\"Underline\">Saquinavir</span><span class=\"Underline\">:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities. <br/> <br/>\n<span class=\"Underline\">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\">\n<br/>  <span class=\"Bold\">Warfarin</span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\">\n<br/> <span class=\"Bold\">Methotrexate </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class=\"Italics\">[see <a href=\"#Section_5.12\">Warnings and Precautions (5.12)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> A temporary withdrawal of esomeprazole magnesium may be considered in some patients receiving high-dose methotrexate. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol) </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Clopidogrel </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]. </span>\n<br/> <br/> <br/>There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel.<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\"> Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Avoid concomitant use with esomeprazole magnesium. Consider use of alternative anti-platelet therapy <span class=\"Italics\">[see <a href=\"#Section_5.7\">Warnings and Precautions (5.7)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Citalopram </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Increased exposure of citalopram leading to an increased risk of QT prolongation <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Cilostazol </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Digoxin </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Potential for increased exposure of digoxin <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Combination Therapy with Clarithromycin and Amoxicillin </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td class=\"Rrule\" valign=\"middle\">\n<br/> Concomitant administration of clarithromycin with other drugs can lead to serious adverse reactions, including potentially fatal arrhythmias, and are contraindicated.<br/> <br/>Amoxicillin also has drug interactions. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> See <span class=\"Italics\">Contraindications, Warnings </span>and <span class=\"Italics\">Precautions </span>in prescribing information for clarithromycin. <br/> <br/> <br/> <br/>See <span class=\"Italics\">Drug Interactions </span>in prescribing information for amoxicillin. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole) </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole magnesium and MMF. Use esomeprazole magnesium with caution in transplant patients receiving MMF <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]</span>. <br/> <br/> <br/> <br/>See the prescribing information for other drugs dependent on gastric pH for absorption. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Tacrolimus </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class=\"Italics\">. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Interactions with Investigations of Neuroendocrine Tumors </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class=\"Italics\">[see <a href=\"#Section_5.11\">Warnings and Precautions (5.11)</a>, <a href=\"#Section_12.2\">Clinical Pharmacology (12.2)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> Discontinue esomeprazole magnesium at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Interaction with Secretin Stimulation Test </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Discontinue esomeprazole magnesium 4 weeks prior to testing <span class=\"Italics\">[see <a href=\"#Section_12.2\">Clinical Pharmacology (12.2)</a>] </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">False Positive Urine Tests for THC </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">\n<br/> There have been reports of false positive urine screening test for tetrahydrocannabinol (THC) in patients receiving PPIs. <br/> <br/>\n</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> An alternative confirmatory method should be considered to verify positive results. <br/> <br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="97%"> <caption> <span>Table 4: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs  </span> </caption> <colgroup> <col width="28.6%"/> <col width="71.4%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">CYP2C19 or CYP3A4 Inducers </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> <span class="Underline">St. John’s Wort, rifampin:</span> Avoid concomitant use with <span class="Italics">[see <a href="#Section_5.10">Warnings and Precautions (5.10)</a>].</span> <br/> <br/> <span class="Underline">Ritonavir-containing products:</span> see prescribing information for specific drugs <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"> <br/> <span class="Bold">Voriconazole </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Increased exposure of esomeprazole <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]. </span> <br/> <br/> </td> </tr> <tr class="Last"> <td align="right" class="Lrule Rrule" valign="middle"> <br/> <span class="Italics">Intervention: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top"> <br/> Dose adjustment of esomeprazole magnesium is not normally required. However, in patients with Zollinger-Ellison syndrome, who may require higher doses, dosage adjustment may be considered. <br/>  <br/>See prescribing information for voriconazole. <br/> <br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"97%\">\n<caption>\n<span>Table 4: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs  \n\t\t\t</span>\n</caption>\n<colgroup>\n<col width=\"28.6%\"/>\n<col width=\"71.4%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">CYP2C19 or CYP3A4 Inducers </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> <span class=\"Underline\">St. John’s Wort, rifampin:</span> Avoid concomitant use with <span class=\"Italics\">[see <a href=\"#Section_5.10\">Warnings and Precautions (5.10)</a>].</span>\n<br/> <br/>\n<span class=\"Underline\">Ritonavir-containing products:</span> see prescribing information for specific drugs <br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\">\n<br/> <span class=\"Bold\">Voriconazole </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Increased exposure of esomeprazole <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]. </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\">\n<br/> <span class=\"Italics\">Intervention: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">\n<br/> Dose adjustment of esomeprazole magnesium is not normally required. However, in patients with Zollinger-Ellison syndrome, who may require higher doses, dosage adjustment may be considered. <br/>  <br/>See prescribing information for voriconazole. <br/> <br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

Risk Summary

There are no adequate and well-controlled studies with esomeprazole in pregnant women. Esomeprazole is the S-isomer of omeprazole. Available epidemiologic data fail to demonstrate an increased risk of major congenital malformations or other adverse pregnancy outcomes with first trimester omeprazole use (see Data). Reproduction studies in rats and rabbits resulted in dose-dependent embryo-lethality at omeprazole doses that were approximately 3.4 to 34 times an oral human dose of 40 mg (based on a body surface area for a 60 kg person).

Teratogenicity was not observed in animal reproduction studies with administration of oral esomeprazole magnesium in rats and rabbits with doses about 68 times and 42 times, respectively, an oral human dose of 40 mg (based on a body surface area basis for a 60 kg person). Changes in bone morphology were observed in offspring of rats dosed through most of pregnancy and lactation at doses equal to or greater than approximately 34 times an oral human dose of 40 mg. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age (see Data).

The estimated background risks of major birth defects and miscarriage for the indicated population are unknown. All pregnancies have a background risk of birth defect, loss or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

Data

Human Data

Esomeprazole is the S-isomer of omeprazole. Four epidemiological studies compared the frequency of congenital abnormalities among infants born to women who used omeprazole during pregnancy with the frequency of abnormalities among infants of women exposed to H2-receptor antagonists or other controls.

A population-based retrospective cohort epidemiological study from the Swedish Medical Birth Registry, covering approximately 99% of pregnancies, from 1995 to 1999, reported on 955 infants (824 exposed during the first trimester with 39 of these exposed beyond first trimester, and 131 exposed after the first trimester) whose mothers used omeprazole during pregnancy. The number of infants exposed in utero to omeprazole that had any malformation, low birth weight, low Apgar score, or hospitalization was similar to the number observed in this population. The number of infants born with ventricular septal defects and the number of stillborn infants was slightly higher in the omeprazole-exposed infants than the expected number in this population.

A population-based retrospective cohort study covering all live births in Denmark from 1996 to 2009, reported on 1,800 live births whose mothers used omeprazole during the first trimester of pregnancy and 837,317 live births whose mothers did not use any proton pump inhibitor. The overall rate of birth defects in infants born to mothers with first trimester exposure to omeprazole was 2.9% and 2.6% in infants born to mothers not exposed to any proton pump inhibitor during the first trimester.

A retrospective cohort study reported on 689 pregnant women exposed to either H2-blockers or omeprazole in the first trimester (134 exposed to omeprazole) and 1,572 pregnant women unexposed to either during the first trimester. The overall malformation rate in offspring born to mothers with first trimester exposure to omeprazole, an H2-blocker, or were unexposed was 3.6%, 5.5%, and 4.1% respectively.

A small prospective observational cohort study followed 113 women exposed to omeprazole during pregnancy (89% with first trimester exposures). The reported rate of major congenital malformations was 4% in the omeprazole group, 2% in controls exposed to non-teratogens, and 2.8% in disease paired controls. Rates of spontaneous and elective abortions, preterm deliveries, gestational age at delivery, and mean birth weight were similar among the groups.

Several studies have reported no apparent adverse short-term effects on the infant when single dose oral or intravenous omeprazole was administered to over 200 pregnant women as premedication for cesarean section under general anesthesia.

Animal Data

Omeprazole

Reproductive studies conducted with omeprazole in rats at oral doses up to 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at doses up to 69.1 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) during organogenesis did not disclose any evidence for a teratogenic potential of omeprazole. In rabbits, omeprazole in a dose range of 6.9 to 69.1 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis produced dose-related increases in embryo-lethality, fetal resorptions, and pregnancy disruptions. In rats, dose-related embryo/fetal toxicity and postnatal developmental toxicity were observed in offspring resulting from parents treated with omeprazole at 13.8 to 138.0 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis), administered prior to mating through the lactation period.

Esomeprazole

No effects on embryo-fetal development were observed in reproduction studies with esomeprazole magnesium in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) or in rabbits at oral doses up to 86 mg/kg/day (about 41 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis.

A pre- and postnatal developmental toxicity study in rats with additional endpoints to evaluate bone development was performed with esomeprazole magnesium at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). Neonatal/early postnatal (birth to weaning) survival was decreased at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). Body weight and body weight gain were reduced and neurobehavioral or general developmental delays in the immediate post-weaning timeframe were evident at doses equal to or greater than 69 mg/kg/day (about 17 times an oral human dose of 40 mg on a body surface area basis). In addition, decreased femur length, width and thickness of cortical bone, decreased thickness of the tibial growth plate and minimal to mild bone marrow hypocellularity were noted at doses equal to or greater than 14 mg/kg/day (about 3.4 times an oral human dose of 40 mg on a body surface area basis). Physeal dysplasia in the femur was observed in offspring of rats treated with oral doses of esomeprazole magnesium at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis).

Effects on maternal bone were observed in pregnant and lactating rats in a pre- and postnatal toxicity study when esomeprazole magnesium was administered at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). When rats were dosed from gestational day 7 through weaning on postnatal day 21, a statistically significant decrease in maternal femur weight of up to 14% (as compared to placebo treatment) was observed at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis).

A pre- and postnatal development study in rats with esomeprazole strontium (using equimolar doses compared to esomeprazole magnesium study) produced similar results in dams and pups as described above.

A follow up developmental toxicity study in rats with further time points to evaluate pup bone development from postnatal day 2 to adulthood was performed with esomeprazole magnesium at oral doses of 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) where esomeprazole administration was from either gestational day 7 or gestational day 16 until parturition. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age.

Risk Summary

Esomeprazole is the S-isomer of omeprazole and limited data suggest that omeprazole may be present in human milk. There are no clinical data on the effects of esomeprazole on the breastfed infant or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for esomeprazole magnesium and any potential adverse effects on the breastfed infant from esomeprazole magnesium or from the underlying maternal condition.

Healing of EE

Pediatric Patients 1 Year to 17 Years of Age

The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 12 years to 17 years for short-term treatment (4 to 8 weeks) for healing of EE. The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 1 year to 11 years for short-term treatment (up to 8 weeks) for healing of EE. Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety and pharmacokinetic data in pediatric patients 1 year to 17 years of age. The safety profile in pediatric patients 1 year to 17 years of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.4)].

Pediatric Patients 1 Month to Less Than 1 Year of Age

The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 1 month to less than 1 year of age for short-term treatment (up to 6 weeks) of EE due to acid-mediated GERD. Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety, pharmacokinetic, and pharmacodynamic data in pediatric patients 1 month to less than 1 year of age. The safety profile in pediatric patients 1 month to less than 1 year of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.2, 12.3)].

The safety and effectiveness of esomeprazole magnesium for the treatment of EE due to acid-mediated GERD in pediatric patients less than 1 month of age have not been established.

Symptomatic GERD

Pediatric Patients 1 Year to 17 Years of Age

The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 12 years to 17 years of age for the short-term treatment (4 weeks) of heartburn and other symptoms associated with GERD. The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 1 year to 11 years of age for the short-term treatment (up to 8 weeks) of heartburn and other symptoms associated with GERD. Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety and pharmacokinetic data in pediatric patients 1 year to 17 years of age. The safety profile in pediatric patients 1 year to 17 years of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.4)].

The safety and effectiveness of esomeprazole magnesium for the treatment of symptomatic GERD in pediatric patients less than 1 year of age have not been established.

Infants 1 Month to Less Than 1 Year of Age

Esomeprazole magnesium was not found to be effective in a multicenter, randomized, double-blind, controlled, treatment-withdrawal study of 98 infants aged 1 month to 11 months for the treatment of symptomatic GERD. Patients were enrolled if they had either a clinical diagnosis of suspected GERD, symptomatic GERD, or endoscopically proven GERD. Twenty of 98 enrolled patients underwent endoscopy, and 6 patients were found to have EE on endoscopy at baseline. All patients received esomeprazole magnesium for delayed-release oral suspension once daily during a two-week, open-label phase of the study. There were 80 patients who attained a pre-specified level of symptom improvement and who entered the double-blind phase, in which they were randomized in equal proportions to receive esomeprazole magnesium or placebo for the next four weeks. Efficacy was assessed by observing the time from randomization to study discontinuation due to symptom worsening during the four-week, treatment-withdrawal phase. There was no statistically significant difference between esomeprazole magnesium and placebo in the rate of discontinuation due to symptom worsening; therefore, these results do not support the use of esomeprazole magnesium for the treatment of symptomatic GERD in infants 1 month to less than 1 year of age.

Other Conditions

The safety and effectiveness of esomeprazole magnesium for the risk reduction of NSAID-associated gastric ulcer, H. pylori eradication to reduce the risk of duodenal ulcer recurrence and treatment of pathological hypersecretory conditions have not been established in pediatric patients.

Juvenile Animal Toxicity Studies

In a juvenile rat toxicity study, esomeprazole was administered with both magnesium and strontium salts at oral doses about 34 to 68 times a daily human dose of 40 mg based on body surface area. Increases in death were seen at the high dose, and at all doses of esomeprazole, there were decreases in body weight, body weight gain, femur weight and femur length, and decreases in overall growth [see Nonclinical Toxicology (13.2)].

Of the total number of patients who received esomeprazole magnesium in clinical trials, 1459 were 65 to 74 years of age and 354 patients were 75 years of age and older.

No overall differences in safety and efficacy were observed between the elderly and younger individuals, and other reported clinical experience has not identified differences in responses between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

In patients with severe hepatic impairment (Child-Pugh Class C) exposure to esomeprazole substantially increased compared to healthy subjects. Dosage modification of esomeprazole magnesium is recommended for patients with severe hepatic impairment for the healing of EE, risk reduction of NSAID-associated gastric ulcer, H. pylori eradication to reduce the risk of duodenal ulcer recurrence, and pathological hypersecretory conditions including Zollinger-Ellison Syndrome [see Dosage and Administration (2.1), Clinical Pharmacology (12.3)].

In patients with mild to moderate liver impairment (Child-Pugh Classes A and B), no dosage adjustment is necessary.

Manifestations in patients exposed to omeprazole, the racemic mixture, at doses up to 2,400 mg (120 times the usual recommended clinical dose) include confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive.

{ "type": "p", "children": [], "text": "Manifestations in patients exposed to omeprazole, the racemic mixture, at doses up to 2,400 mg (120 times the usual recommended clinical dose) include confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive. " }

If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage.

{ "type": "p", "children": [], "text": "If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage." }

The active ingredient in esomeprazole magnesium  for delayed-release oral suspension is bis(5-methoxy-2-[(S)-[(4-methoxy-3,5-dimethyl-2-pyridinyl)methyl]sulfinyl]-1H-benzimidazole-1-yl) magnesium trihydrate, a PPI. Esomeprazole is the S-isomer of omeprazole, which is a mixture of the S- and R- isomers. (Initial U.S. approval of esomeprazole magnesium: 2001). Its molecular formula is (C17H18N3O3S)2Mg x 3 H2O with molecular weight of 767.2 as a trihydrate and 713.1 on an anhydrous basis. The structural formula is:

{ "type": "p", "children": [], "text": "The active ingredient in esomeprazole magnesium  for delayed-release oral suspension is bis(5-methoxy-2-[(S)-[(4-methoxy-3,5-dimethyl-2-pyridinyl)methyl]sulfinyl]-1H-benzimidazole-1-yl) magnesium trihydrate, a PPI. Esomeprazole is the S-isomer of omeprazole, which is a mixture of the S- and R- isomers. (Initial U.S. approval of esomeprazole magnesium: 2001). Its molecular formula is (C17H18N3O3S)2Mg x 3 H2O with molecular weight of 767.2 as a trihydrate and 713.1 on an anhydrous basis. The structural formula is:\n" }

The magnesium salt is a white to slightly colored powder. It contains 3 moles of water of solvation and is soluble in methanol, slightly soluble in water, practically insoluble in heptane. The stability of esomeprazole magnesium is a function of pH; it rapidly degrades in acidic media, but it has acceptable stability under alkaline conditions. At pH 6.8 (buffer), the half-life of the magnesium salt is about 19 hours at 25°C and about 8 hours at 37°C. Esomeprazole magnesium is supplied in packets for a delayed-release oral suspension. Each packet of esomeprazole magnesium for delayed-release oral suspension contains 10 mg of esomeprazole (equivalent to 11.1 mg esomeprazole magnesium trihydrate USP) in the form of enteric-coated granules with the following inactive ingredients: hydroxypropyl cellulose, hypromellose, magnesium carbonate, magnesium oxide, methacrylic acid and ethyl acrylate copolymer dispersion (contains copolymer based on ethyl acrylate and methacrylic acid, polysorbate 80 and sodium lauryl sulfate), mono-and di-glycerides, polysorbate 80, sugar spheres (which contains liquid glucose, starch (maize) and sucrose), talc and triethyl citrate. Each packet of esomeprazole magnesium for delayed-release oral suspension contains esomeprazole, in the form of same enteric-coated granules used in NEXIUM delayed-release capsules, and also inactive granules. The inactive granules are composed of the following ingredients: citric acid anhydrous, crospovidone, dextrose, ferric oxide yellow, hydroxypropyl cellulose and xanthan gum. The esomeprazole granules and inactive granules are constituted with water to form a suspension and are given by oral, nasogastric, or gastric administration.

{ "type": "p", "children": [], "text": "The magnesium salt is a white to slightly colored powder. It contains 3 moles of water of solvation and is soluble in methanol, slightly soluble in water, practically insoluble in heptane. The stability of esomeprazole magnesium is a function of pH; it rapidly degrades in acidic media, but it has acceptable stability under alkaline conditions. At pH 6.8 (buffer), the half-life of the magnesium salt is about 19 hours at 25°C and about 8 hours at 37°C.\n Esomeprazole magnesium is supplied in packets for a delayed-release oral suspension. Each packet of esomeprazole magnesium for delayed-release oral suspension contains 10 mg of esomeprazole (equivalent to 11.1 mg esomeprazole magnesium trihydrate USP) in the form of enteric-coated granules with the following inactive ingredients: hydroxypropyl cellulose, hypromellose, magnesium carbonate, magnesium oxide, methacrylic acid and ethyl acrylate copolymer dispersion (contains copolymer based on ethyl acrylate and methacrylic acid, polysorbate 80 and sodium lauryl sulfate), mono-and di-glycerides, polysorbate 80, sugar spheres (which contains liquid glucose, starch (maize) and sucrose), talc and triethyl citrate.\n Each packet of esomeprazole magnesium for delayed-release oral suspension contains esomeprazole, in the form of same enteric-coated granules used in NEXIUM delayed-release capsules, and also inactive granules.\n The inactive granules are composed of the following ingredients: citric acid anhydrous, crospovidone, dextrose, ferric oxide yellow, hydroxypropyl cellulose and xanthan gum. The esomeprazole granules and inactive granules are constituted with water to form a suspension and are given by oral, nasogastric, or gastric administration." }

Esomeprazole belongs to a class of antisecretory compounds, the substituted benzimidazoles, that suppress gastric acid secretion by specific inhibition of the H+/K+ ATPase enzyme system at the secretory surface of the gastric parietal cell. Esomeprazole is protonated and converted in the acidic compartment of the parietal cell forming the active inhibitor, the achiral sulphenamide. Because this enzyme system is regarded as the acid (proton) pump within the gastric mucosa, esomeprazole has been characterized as a gastric acid-pump inhibitor, in that it blocks the final step of acid production. This effect is dose-related and leads to inhibition of both basal and stimulated acid secretion irrespective of the stimulus.

Antisecretory Activity

Adults

The effect of esomeprazole on intragastric pH was determined in adult patients with symptomatic GERD in two separate studies. In the first study of 36 patients, NEXIUM 40 mg and 20 mg delayed-release capsules were administered once daily over 5 days as shown in Table 5: 

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 5: Effect of Esomeprazole on Intragastric pH on Day 5 (N=36) Following Once Daily Dosing of NEXIUM Delayed-Release Capsules in Adult Patients with Symptomatic GERD</span> </caption> <colgroup> <col width="41%"/> <col width="27%"/> <col width="30%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" rowspan="2" valign="top">Parameter <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle">NEXIUM Delayed-Release Capsules<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">40 mg once daily<br/> </td><td align="center" class="Rrule" valign="middle">20 mg once daily<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">% Time Gastric pH &gt;4<span class="Italics"><span class="Sup">1</span></span>(Hours) <br/> </td><td align="center" class="Rrule" valign="middle">70%<span class="Italics"><span class="Sup">2</span></span> <br/>(16.8 h)<br/> </td><td align="center" class="Rrule" valign="middle">53%<br/>(12.7 h)<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Coefficient of variation <br/> </td><td align="center" class="Rrule" valign="middle">26%<br/> </td><td align="center" class="Rrule" valign="middle">37%<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Median 24 Hour pH <br/> </td><td align="center" class="Rrule" valign="middle">4.9<span class="Italics"><span class="Sup">2</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">4.1<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">Coefficient of variation <br/> </td><td align="center" class="Rrule" valign="middle">16%<br/> </td><td align="center" class="Rrule" valign="middle">27%<br/> </td> </tr> </tbody> </table></div>

1. Gastric pH was measured over a 24-hour period

2. p< 0.01 NEXIUM 40 mg vs. NEXIUM 20 mg

In a second study, the effect on intragastric pH of NEXIUM 40 mg delayed-release capsules administered once daily over a five-day period was similar to the first study, (% time with pH > 4 was 68% or 16.3 hours).

Pediatrics

In infants (1 to 11 months old, inclusive) with GERD given esomeprazole magnesium for delayed-release oral suspension 1 mg/kg once daily, the percent time with intragastric pH > 4 increased from 29% at baseline to 69% on Day 7, which is similar to the pharmacodynamic effect in adults.

Serum Gastrin Effects

The effect of esomeprazole on serum gastrin concentrations was evaluated in approximately 2,700 patients in clinical trials of oral esomeprazole for up to 8 weeks and in over 1,300 patients for up to 12 months. The mean fasting gastrin level increased in a dose-related manner. The increase in serum gastrin concentrations reached a plateau within two to three months of therapy and returned to baseline levels within four weeks after discontinuation of therapy.

Increased gastrin causes enterochromaffin-like cell hyperplasia and increased serum Chromogranin A (CgA) levels. The increased CgA levels may cause false positive results in diagnostic investigations for neuroendocrine tumors [see Warnings and Precautions (5.11)]

Enterochromaffin-like (ECL) Cell Effects

Human gastric biopsy specimens have been obtained from more than 3,000 patients (both pediatrics and adults) treated with omeprazole in long-term clinical trials. The incidence of ECL cell hyperplasia in these studies increased with time; however, no case of ECL cell carcinoids, dysplasia, or neoplasia has been found in these patients [see Nonclinical Toxicology (13.1)]

In over 1,000 patients treated with oral esomeprazole (10 mg, 20 mg or 40 mg/day) for up to 12 months, the prevalence of ECL cell hyperplasia increased with time and dose. No patient developed ECL cell carcinoids, dysplasia, or neoplasia in the gastric mucosa.

Endocrine Effects

Esomeprazole had no effect on thyroid function in adults when given NEXIUM 20 mg or 40 mg delayed-release capsules once daily for 4 weeks. Other effects of esomeprazole on the endocrine system were assessed in studies of omeprazole. Oral doses of omeprazole 30 mg or 40 mg once daily for 2 to 4 weeks had no effect on carbohydrate metabolism, circulating levels of parathyroid hormone, cortisol, estradiol, testosterone, prolactin, cholecystokinin, or secretin.

Absorption

NEXIUM delayed-release capsules and esomeprazole magnesium for delayed-release oral suspension showed similar bioavailability after a single dose (40 mg) administration in 94 healthy male and female subjects under fasting conditions. After oral administration, peak plasma levels (Cmax) of esomeprazole occur at approximately 1.5 hours (Tmax). The Cmax increases proportionally when the dose is increased, and there is a three-fold increase in the area under the plasma concentration-time curve (AUC) from 20 to 40 mg. At repeated once-daily dosing with 40 mg, the systemic bioavailability is approximately 90% compared to 64% after a single dose of 40 mg. The mean exposure (AUC) to esomeprazole increases from 4.32 micromol*hr/L on Day 1 to 11.2 micromol*hr/L on Day 5 after 40 mg once daily dosing.

The AUC after administration of a single 40 mg dose of NEXIUM delayed-release capsules is decreased by 43% to 53% after food intake compared to fasting conditions [see Dosage and Administration (2.3)]. The pharmacokinetics of esomeprazole in adult patients with symptomatic GERD following repeated once daily administration of 20 mg and 40 mg NEXIUM delayed-release capsules over a period of five days are shown in Table 6: 

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 6: Geometric Mean (95% CI) Pharmacokinetic Parameters of Esomeprazole on Day 5 Following Once Daily Dosing of NEXIUM Delayed-Release Capsules in Adult Patients with Symptomatic GERD</span> </caption> <colgroup> <col width="42%"/> <col width="28%"/> <col width="29%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" rowspan="2" valign="middle"><span class="Bold">Parameter <span class="Italics"><span class="Sup">1</span></span> (CV)</span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">NEXIUM delayed-release capsules</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">40 mg once daily</span> <br/> <span class="Bold">(n=36)</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">20 mg once daily</span> <br/> <span class="Bold">(n=36)</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">AUC (micromol·h/L) <br/> </td><td align="center" class="Rrule" valign="middle">12.6 (42%)<br/> </td><td align="center" class="Rrule" valign="middle">4.2 (59%)<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">C<span class="Sub">max</span> (micromol/L) <br/> </td><td align="center" class="Rrule" valign="middle">4.7 (37%)<br/> </td><td align="center" class="Rrule" valign="middle">2.1 (45%)<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">T<span class="Sub">max </span>(hours) <br/> </td><td align="center" class="Rrule" valign="middle">1.6<br/> </td><td align="center" class="Rrule" valign="middle">1.6<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">t<span class="Sub">1/2 </span>(hours) <br/> </td><td align="center" class="Rrule" valign="middle">1.5<br/> </td><td align="center" class="Rrule" valign="middle">1.2<br/> </td> </tr> </tbody> </table></div>

1. Values represent the geometric mean, except the Tmax, which is the arithmetic mean; CV = Coefficient of variation

Esomeprazole is a time-dependent inhibitor of CYP2C19, resulting in autoinhibition and nonlinear pharmacokinetics. The systemic exposure increases in a more than dose proportional manner after multiple oral doses of esomeprazole. Compared to the first dose, the systemic exposure (Cmax and AUC0-24h) at steady state following once a day dosing increased by 43% and 90%, respectively, compared to after the first dose for the 20 mg dose and increased by 95% and 159%, respectively, for the 40 mg dose.

Distribution

Esomeprazole is 97% bound to plasma proteins. Plasma protein binding is constant over the concentration range of 2 to 20 micromol/L. The apparent volume of distribution at steady state in healthy subjects is approximately 16 L.

Elimination

Metabolism

Esomeprazole is extensively metabolized in the liver by the cytochrome P450 (CYP) enzyme system. The metabolites of esomeprazole lack antisecretory activity. The major part of esomeprazole’s metabolism is dependent upon the CYP2C19 isoenzyme, which forms the hydroxy and desmethyl metabolites. The remaining amount is dependent on CYP3A4 which forms the sulphone metabolite.

Excretion

The plasma elimination half-life of esomeprazole is approximately 1 to 1.5 hours. Less than 1% of parent drug is excreted in the urine. Approximately 80% of an oral dose of esomeprazole is excreted as inactive metabolites in the urine, and the remainder is found as inactive metabolites in the feces.

Combination Therapy with Amoxicillin and Clarithromycin

NEXIUM delayed-release capsules 40 mg once daily was given in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily for 7 days to 17 healthy male and female subjects. The mean steady state AUC and Cmax of esomeprazole increased by 70% and 18%, respectively during combination therapy compared to treatment with NEXIUM alone. The observed increase in esomeprazole exposure during co-administration with amoxicillin and clarithromycin is not expected to be clinically relevant.

The pharmacokinetic parameters for amoxicillin and clarithromycin were similar during combination therapy and administration of each drug alone. However, the mean AUC and Cmax for 14-hydroxyclarithromycin increased by 19% and 22%, respectively, during combination therapy compared to treatment with clarithromycin alone. This increase in exposure to 14-hydroxyclarithromycin is not considered to be clinically relevant.

Specific Populations

Geriatric Patients

The AUC and Cmax values of esomeprazole were slightly higher (25% and 18%, respectively) in the elderly as compared to younger subjects at steady state. This increase in exposure is not considered clinically relevant.

Pediatric Patients

1 Month to 11 Months of Age

The pharmacokinetic parameters following repeated dose administration of esomeprazole magnesium 1 mg/kg once daily for 7 to 8 days in 1 month to 11-month-old infants with GERD are summarized in Table 7.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 7: Summary of Esomeprazole Pharmacokinetic Parameters Following Once Daily Dosing of Oral Esomeprazole Magnesium for 7 to 8 Days in 1 Month to 1 Year Old Infants with GERD</span> </caption> <colgroup> <col width="42%"/> <col width="57%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle"><span class="Bold">Parameter</span> <br/> </td><td class="Rrule" valign="middle"><span class="Bold">Esomeprazole Magnesium 1 mg/kg Orally Once Daily</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">AUC (micromol·h/L) (n=7)<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td class="Rrule" valign="middle">3.51<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">C<span class="Sub">ss,max </span>(micromol/L) (n=15)<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td class="Rrule" valign="middle">0.87<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">t<span class="Sub">½</span> (h) (n=8)<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td class="Rrule" valign="middle">0.93<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">t<span class="Sub">max </span>(h) (n=15)<span class="Italics"><span class="Sup">2</span></span> <br/> </td><td class="Rrule" valign="middle">3.0<br/> </td> </tr> </tbody> </table></div>

1. Geometric mean 2. Median

Subsequent pharmacokinetic simulation analyses showed that for pediatric patients 1 month to 11 months of age, a dosage regimen of 2.5 mg once daily (body weight 3 to 5 kg), 5 mg once daily (body weight more than 5 to 7.5 kg) and 10 mg once daily for (body weight more than 7.5 to 12 kg) would achieve comparable steady-state plasma exposures (AUC) to that observed with 10 mg once daily in patients 1 year to 11 year of age and 20 mg once daily in patients 12 years to 18 years of age, as well as adults.

Apparent clearance (CL/F) increases with age in pediatric patients with GERD from 1 month to 2 years of age.  

1 Year to 11 Years of Age

The pharmacokinetics of esomeprazole were studied in pediatric patients with GERD aged     1 year to 11 years. Following once daily dosing with esomeprazole magnesium for delayed-release oral suspension for 5 days, the total exposure (AUC) for the 10 mg dosage in patients aged 6 years to 11 years was similar to that seen with the 20 mg dosage in adults and adolescents aged 12 years to 17 years. The total exposure for the 10 mg dosage in patients aged 1 year to 5 years was approximately 30% higher than the 10 mg dosage in patients aged 6 years to 11 years. The total exposure for the 20 mg dosage in patients aged 6 years to 11 years was higher than that observed with the 20 mg dosage in patients aged 12 years to 17 years and adults, but lower than that observed with the 40 mg dosage in 12 to 17 year-olds and adults. See Table 8.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 8: Summary of Esomeprazole Pharmacokinetic Parameters Following Once Daily Dosing of Esomeprazole Magnesium for Delayed-Release Oral Suspension for 5 Days in 1 Year to 11 Year Old Patients with GERD</span> </caption> <colgroup> <col width="22%"/> <col width="24%"/> <col width="28%"/> <col width="25%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" rowspan="3" valign="middle"><span class="Bold">Parameter</span> <br/> </td><td align="center" class="Rrule" colspan="3" valign="middle"><span class="Bold">Esomeprazole Magnesium For Delayed-Release Oral Suspension</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">1 Year to 5 Years</span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">6 Years to 11 Years</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">10 mg once daily (N=8)</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">10 mg once daily (N=7)</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">20 mg once daily (N=6)</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">AUC (micromol·h/L)<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">4.83<br/> </td><td align="center" class="Rrule" valign="middle">3.70<br/> </td><td align="center" class="Rrule" valign="middle">6.28<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">C<span class="Sub">max</span> (micromol/L)<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">2.98<br/> </td><td align="center" class="Rrule" valign="middle">1.77<br/> </td><td align="center" class="Rrule" valign="middle">3.73<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">t<span class="Sub">max</span> (h)<span class="Italics"><span class="Sup">2</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">1.44<br/> </td><td align="center" class="Rrule" valign="middle">1.79<br/> </td><td align="center" class="Rrule" valign="middle">1.75<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">t<span class="Sub">½λz</span> (h)<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">0.74<br/> </td><td align="center" class="Rrule" valign="middle">0.88<br/> </td><td align="center" class="Rrule" valign="middle">0.73<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">Cl/F (L/h)<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">5.99<br/> </td><td align="center" class="Rrule" valign="middle">7.84<br/> </td><td align="center" class="Rrule" valign="middle">9.22<br/> </td> </tr> </tbody> </table></div>

1. Geometric mean

2. Arithmetic mean

12 Years to 17 Years of Age

The pharmacokinetics of NEXIUM were studied in 28 adolescent patients with GERD aged 12 to 17 years inclusive, in a single center study. Patients were randomized to receive NEXIUM 20 mg or 40 mg once daily for 8 days. Mean Cmax and AUC values of esomeprazole were not affected by body weight or age; and more than dose-proportional increases in mean Cmax and AUC values were observed between the two dose groups in the study. Overall, NEXIUM pharmacokinetics in adolescent patients aged 12 to 17 years were similar to those observed in adult patients with symptomatic GERD. See Table 9.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 9: Comparison of Esomeprazole Pharmacokinetic Parameters Following Once Daily Dosing of NEXIUM Delayed-Release Capsules in Pediatric Patients 12 Years to 17 Years with GERD and Adults with Symptomatic GERD<span class="Sup">1</span></span> </caption> <colgroup> <col width="21%"/> <col width="19%"/> <col width="19%"/> <col width="19%"/> <col width="18%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" rowspan="3" valign="middle"><span class="Bold">Parameter</span> <br/> </td><td align="center" class="Rrule" colspan="4" valign="middle"><span class="Bold">NEXIUM Delayed-Release Capsules</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">12 Years to 17 Years (N=28)</span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">Adults (N=36)</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">20 mg once daily for 8 days</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">40 mg once daily for 8 days</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">20 mg once daily for 5 days</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">40 mg once daily for 5 days</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">AUC (micromol·h/L)<br/> </td><td align="center" class="Rrule" valign="middle">3.65<br/> </td><td align="center" class="Rrule" valign="middle">13.86<br/> </td><td align="center" class="Rrule" valign="middle">4.2<br/> </td><td align="center" class="Rrule" valign="middle">12.6<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">C<span class="Sub">max</span> (micromol/L)<br/> </td><td align="center" class="Rrule" valign="middle">1.45<br/> </td><td align="center" class="Rrule" valign="middle">5.13<br/> </td><td align="center" class="Rrule" valign="middle">2.1<br/> </td><td align="center" class="Rrule" valign="middle">4.7<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">t<span class="Sub">max</span> (h)<br/> </td><td align="center" class="Rrule" valign="middle">2.00<br/> </td><td align="center" class="Rrule" valign="middle">1.75<br/> </td><td align="center" class="Rrule" valign="middle">1.6<br/> </td><td align="center" class="Rrule" valign="middle">1.6<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">t<span class="Sub">½λz</span> (h)<br/> </td><td align="center" class="Rrule" valign="middle">0.82<br/> </td><td align="center" class="Rrule" valign="middle">1.22<br/> </td><td align="center" class="Rrule" valign="middle">1.2<br/> </td><td align="center" class="Rrule" valign="middle">1.5<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" colspan="5" valign="middle">Data presented are geometric means for AUC, C<span class="Sub">max</span> and t<span class="Sub">½λz</span>, and median value for t<span class="Sub">max</span>.<br/> </td> </tr> </tbody> </table></div>

1. Data obtained from two independent studies

Male and Female Patients

The AUC and Cmax values of esomeprazole were slightly higher (13%) in females than in males at steady state when dosed orally. This increase in exposure is not considered clinically relevant.

Patients with Renal Impairment

The pharmacokinetics of NEXIUM in patients with renal impairment are not expected to be altered relative to healthy subjects as less than 1% of esomeprazole is excreted unchanged in urine.

Patients with Hepatic Impairment

The steady state pharmacokinetics of esomeprazole obtained after administration of NEXIUM delayed-release capsules 40 mg orally once daily to patients with mild (Child-Pugh Class A, n=4), moderate (Child-Pugh Class B, n=4), and severe (Child-Pugh Class C, n=4) hepatic impairment were compared to those obtained in 36 male and female GERD patients with normal liver function. In patients with mild and moderate hepatic impairment, the AUCs were within the range that could be expected in patients with normal liver function. In patients with severe hepatic impairment the AUCs were 2 to 3 times higher than in the patients with normal liver function [see Use in Specific Populations (8.6)].

Drug Interaction Studies

Effect of Esomeprazole/Omeprazole on Other Drugs

In vitro and in vivo studies have shown that esomeprazole is not likely to inhibit CYPs 1A2, 2A6, 2C9, 2D6, 2E1 and 3A4.

Antiretrovirals  

For some antiretroviral drugs, such as rilpivirine, atazanavir and nelfinavir, decreased serum concentrations have been reported when given together with omeprazole [see Drug Interactions (7)].

Rilpivirine:

Following multiple doses of rilpivirine (150 mg, daily) and omeprazole (20 mg, daily), AUC was decreased by 40%, Cmax by 40%, and Cmin by 33% for rilpivirine [see Contraindications (4)].

Nelfinavir:

Following multiple doses of nelfinavir (1250 mg, twice daily) and omeprazole (40 mg daily), AUC was decreased by 36% and 92%, Cmax by 37% and 89% and Cmin by 39% and 75% respectively for nelfinavir and M8.

Atazanavir:

Following multiple doses of atazanavir (400 mg, daily) and omeprazole (40 mg, daily, 2 hours before atazanavir), AUC was decreased by 94%, Cmax by 96%, and Cmin by 95%.

Saquinavir:

Following multiple dosing of saquinavir/ritonavir (1000/100 mg) twice daily for 15 days with omeprazole 40 mg daily co-administered days 11 to 15. The AUC was increased by 82%, Cmax by 75%, and Cmin by 106%. The mechanism behind this interaction is not fully elucidated. 

Clopidogrel

In a crossover study, healthy subjects were administered clopidogrel (300 mg loading dose followed by 75 mg per day as the maintenance dosage for 28 days) alone and with esomeprazole (40 mg orally once daily at the same time as clopidogrel) for 29 days. Exposure to the active metabolite of clopidogrel was reduced by 35% to 40% over this time period when clopidogrel and esomeprazole were administered together. Pharmacodynamic parameters were also measured and demonstrated that the change in inhibition of platelet aggregation was related to the change in the exposure to clopidogrel active metabolite [see Warnings and Precautions (5.7) and Drug Interactions (7)].  

Mycophenolate Mofetil

Administration of omeprazole 20 mg twice daily for 4 days and a single 1000 mg dose of MMF approximately one hour after the last dose of omeprazole to 12 healthy subjects in a cross-over study resulted in a 52% reduction in the Cmax and 23% reduction in the AUC of MPA [see Drug Interactions (7)].  

Cilostazol

Omeprazole acts as an inhibitor of CYP2C19. Omeprazole, given in doses of 40 mg daily for one week to 20 healthy subjects in cross-over study, increased Cmax and AUC of cilostazol by 18% and 26% respectively. The Cmax and AUC of one of the active metabolites, 3,4-dihydro-cilostazol, which has 4 to 7 times the activity of cilostazol, were increased by 29% and 69%, respectively. Co-administration of cilostazol with omeprazole is expected to increase concentrations of cilostazol and the above mentioned active metabolite [see Drug Interactions (7)].

Diazepam

Co-administration of esomeprazole 30 mg and diazepam, a CYP2C19 substrate, resulted in a 45% decrease in clearance of diazepam. Increased plasma levels of diazepam were observed 12 hours after dosing and onwards. However, at that time, the plasma levels of diazepam were below the therapeutic interval, and thus this interaction is unlikely to be of clinical relevance.   

Digoxin

Concomitant administration of omeprazole 20 mg once daily and digoxin in healthy subjects increased the bioavailability of digoxin by 10% (30% in two subjects) [see Drug Interactions (7)].   

Other Drugs

Concomitant administration of esomeprazole and either naproxen (non-selective NSAID) did not identify any clinically relevant changes in the pharmacokinetic profiles of these NSAIDs.

Effect of Other Drugs on Esomeprazole/Omeprazole

St. John’s Wort  

In a cross-over study in 12 healthy male subjects, St. John’s Wort (300 mg three times daily for 14 days) significantly decreased the systemic exposure of omeprazole in CYP2C19 poor metabolizers (Cmax and AUC both decreased by 38%) and extensive metabolizers (Cmax and AUC decreased by 50% and 44%, respectively) [see Drug Interactions (7)].  

Voriconazole  

Concomitant administration of omeprazole and voriconazole (a combined inhibitor of CYP2C19 and CYP3A4) resulted in more than doubling of the omeprazole exposure. When voriconazole (400 mg every 12 hours for one day, followed by 200 mg once daily for 6 days) was given with omeprazole (40 mg once daily for 7 days) to healthy subjects, the steady-state Cmax and AUC0-24 of omeprazole significantly increased: an average of 2 times (90% CI: 1.8, 2.6) and 4 times (90% CI: 3.3, 4.4), respectively, as compared to when omeprazole was given without voriconazole [see Drug Interactions (7)].   

Other Drugs

Co-administration of esomeprazole with oral contraceptives, diazepam, phenytoin, quinidine, naproxen (non-selective NSAID) did not seem to change the pharmacokinetic profile of esomeprazole.

NEXIUM, amoxicillin, and clarithromycin triple therapy has been shown to be active against most strains of Helicobacter pylori (H. pylori) in vitro and in clinical infections [see Indications and Usage (1) and Clinical Studies (14)].

Helicobacter pylori: Susceptibility testing of H. pylori isolates was performed for amoxicillin and clarithromycin using agar dilution methodology, and minimum inhibitory concentrations (MICs) were determined.

Pretreatment Resistance: Clarithromycin pretreatment resistance rate (MIC ≥ 1 mcg/mL) to H. pylori was 15% (66/445) at baseline in all treatment groups combined. A total of > 99% (394/395) of patients had H. pylori isolates that were considered to be susceptible (MIC ≤ 0.25 mcg/mL) to amoxicillin at baseline. One patient had a baseline H. pylori isolate with an amoxicillin MIC = 0.5 mcg/mL.

Clarithromycin Susceptibility Test Results and Clinical/Bacteriologic Outcomes: The baseline H. pylori clarithromycin susceptibility results and the H. pylori eradication results at the Day 38 visit are shown in Table 10:

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="97%"> <caption> <span>Table 10: Clarithromycin Susceptibility Test Results and Clinical/Bacteriological Outcomes<span class="Sup">1</span><span class="Sup">  </span>for Triple Therapy (NEXIUM Delayed-Release Capsules 40 mg once daily, Amoxicillin 1000 mg twice daily and Clarithromycin 500 mg twice daily for 10 days)</span> </caption> <colgroup> <col width="29%"/> <col width="22%"/> <col width="13%"/> <col width="10%"/> <col width="10%"/> <col width="12%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Clarithromycin Pretreatment Results</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold"><span class="Italics">H. pylori </span></span><span class="Bold">negative (Eradicated)</span> <br/> </td><td align="center" class="Rrule" colspan="4" valign="middle"><span class="Bold"><span class="Italics">H. pylori </span></span><span class="Bold">positive (Not Eradicated) </span> <br/> <span class="Bold">Post-treatment susceptibility results</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"></td><td align="center" class="Rrule" valign="middle"></td><td align="center" class="Rrule" valign="middle">S<span class="Italics"><span class="Sup">2</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">I<span class="Italics"><span class="Sup">2</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">R<span class="Italics"><span class="Sup">2</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">No MIC<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Susceptible<span class="Italics"><span class="Sup">2  </span>              </span>182<br/> </td><td align="center" class="Rrule" valign="middle">162<br/> </td><td align="center" class="Rrule" valign="middle">4<br/> </td><td align="center" class="Rrule" valign="middle">0<br/> </td><td align="center" class="Rrule" valign="middle">2<br/> </td><td align="center" class="Rrule" valign="middle">14<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Intermediate<span class="Italics"><span class="Sup">2</span></span>               1<br/> </td><td align="center" class="Rrule" valign="middle">1<br/> </td><td align="center" class="Rrule" valign="middle">0<br/> </td><td align="center" class="Rrule" valign="middle">0<br/> </td><td align="center" class="Rrule" valign="middle">0<br/> </td><td align="center" class="Rrule" valign="middle">0<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">Resistant<span class="Italics"><span class="Sup">2</span></span>                    29<br/> </td><td align="center" class="Rrule" valign="middle">13<br/> </td><td align="center" class="Rrule" valign="middle">1<br/> </td><td align="center" class="Rrule" valign="middle">0<br/> </td><td align="center" class="Rrule" valign="middle">13<br/> </td><td align="center" class="Rrule" valign="middle">2<br/> </td> </tr> </tbody> </table></div>

1. Includes only patients with pretreatment and post-treatment clarithromycin susceptibility test results 2. Susceptible (S) MIC ≤ 0.25 mcg/mL, Intermediate (I) MIC = 0.5 mcg/mL, Resistant (R) MIC ≥ 1.0 mcg/mL

Patients not eradicated of H. pylori following triple therapy with NEXIUM, amoxicillin and clarithromycin will likely have clarithromycin resistant H. pylori isolates. Therefore, clarithromycin susceptibility testing should be done, when possible. Patients with clarithromycin resistant H. pylori should not be re-treated with a clarithromycin-containing regimen.

Amoxicillin Susceptibility Test Results and Clinical/Bacteriological Outcomes:

In patients treated with NEXIUM, amoxicillin and clarithromycin in clinical trials, 83% (176/212) of the patients who had pretreatment amoxicillin susceptible MICs (≤ 0.25 mcg/mL) were eradicated of H. pylori, and 17% (36/212) were not eradicated of H. pylori. Of the 36 patients who were not eradicated of H. pylori, 16 had no post-treatment susceptibility test results and 20 had post-treatment H. pylori isolates with amoxicillin susceptible MICs. Fifteen of the patients who were not eradicated of H. pylori also had post-treatment H. pylori isolates with clarithromycin resistant MICs. There were no patients with H. pylori isolates who developed treatment emergent resistance to amoxicillin.

Susceptibility Test for Helicobacter pylori: For susceptibility testing information about Helicobacter pylori, see Microbiology section in prescribing information for clarithromycin and amoxicillin.

Effects on Gastrointestinal Microbial Ecology: Decreased gastric acidity due to any means, including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with PPIs may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile in hospitalized patients.

CYP2C19, a polymorphic enzyme, is involved in the metabolism of esomeprazole. The CYP2C19*1 allele is fully functional while the CYP2C19*2 and *3 alleles are nonfunctional. There are other alleles associated with no or reduced enzymatic function. Patients carrying two fully functional alleles are extensive metabolizers and those carrying two loss-of-function alleles are poor metabolizers. The systemic exposure to esomeprazole varies with a patient’s metabolism status: poor metabolizers > intermediate metabolizers > extensive metabolizers. Approximately 3% of Caucasians and 15 to 20% of Asians are CYP2C19 poor metabolizers.

Systemic esomeprazole exposures were modestly higher (approximately 17%) in CYP2C19 intermediate metabolizers (IM; n=6) compared to extensive metabolizers (EM; n=17) of CYP2C19. Similar pharmacokinetic differences were noted across these genotypes in a study of Chinese healthy subjects that included 7 EMs and 11 IMs. There is very limited pharmacokinetic information for poor metabolizers (PM) from these studies.

At steady state following once daily administration of esomeprazole 40 mg, the ratio of AUC in poor metabolizers to AUC in the rest of the population (EMs) is approximately 1.5. This change in exposure is not considered clinically meaningful.

The carcinogenic potential of esomeprazole magnesium was assessed using studies of omeprazole, of which esomeprazole is an enantiomer. In two 24-month oral carcinogenicity studies in rats, omeprazole at daily doses of 1.7, 3.4, 13.8, 44, and 140.8 mg/kg/day (about 0.4 to 34 times the human dose of 40 mg/day expressed on a body surface area basis) produced gastric ECL cell carcinoids in a dose-related manner in both male and female rats; the incidence of this effect was markedly higher in female rats, which had higher blood levels of omeprazole. Gastric carcinoids seldom occur in the untreated rat. In addition, ECL cell hyperplasia was present in all treated groups of both sexes. In one of these studies, female rats were treated with 13.8 mg omeprazole/kg/day (about 3.4 times the human dose of 40 mg/day on a body surface area basis) for 1 year, then followed for an additional year without the drug. No carcinoids were seen in these rats. An increased incidence of treatment-related ECL cell hyperplasia was observed at the end of 1 year (94% treated vs. 10% controls). By the second year the difference between treated and control rats was much smaller (46% vs. 26%) but still showed more hyperplasia in the treated group. Gastric adenocarcinoma was seen in one rat (2%). No similar tumor was seen in male or female rats treated for 2 years. For this strain of rat no similar tumor has been noted historically, but a finding involving only one tumor is difficult to interpret. A 78-week mouse carcinogenicity study of omeprazole did not show increased tumor occurrence, but the study was not conclusive.

Esomeprazole was negative in the Ames mutation test, in the in vivo rat bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test. Esomeprazole, however, was positive in the in vitro human lymphocyte chromosome aberration test. Omeprazole was positive in the in vitro human lymphocyte chromosome aberration test, the in vivo mouse bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test.

The potential effects of esomeprazole on fertility and reproductive performance were assessed using omeprazole studies. Omeprazole at oral doses up to 138 mg/kg/day in rats (about 34 times the human dose of 40 mg/day on a body surface area basis) was found to have no effect on reproductive performance of parental animals.

Reproduction Studies Reproduction studies have been performed in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at oral doses up to 86 mg/kg/day (about 42 times an oral human dose of 40 mg on a body surface area basis) and have revealed no evidence of impaired fertility or harm to the fetus due to esomeprazole [see Use in Specific Populations (8.1)].

Juvenile Animal Study

A 28-day toxicity study with a 14-day recovery phase was conducted in juvenile rats with esomeprazole magnesium at doses of 70 to 280 mg /kg/day (about 17 to 68 times a daily oral human dose of 40 mg on a body surface area basis). An increase in the number of deaths at the high dose of 280 mg/kg/day was observed when juvenile rats were administered esomeprazole magnesium from postnatal day 7 through postnatal day 35. In addition, doses equal to or greater than 140 mg/kg/day (about 34 times a daily oral human dose of 40 mg on a body surface area basis), produced treatment-related decreases in body weight (approximately 14%) and body weight gain, decreases in femur weight and femur length, and affected overall growth. Comparable findings described above have also been observed in this study with another esomeprazole salt, esomeprazole strontium, at equimolar doses of esomeprazole.

The healing rates of NEXIUM delayed-release capsules 40 mg, NEXIUM delayed-release capsules 20 mg, and omeprazole delayed-release capsules 20 mg (the approved dose for this indication) once daily were evaluated in adult patients with endoscopically diagnosed EE in four multicenter, double-blind, randomized studies. The healing rates at Weeks 4 and 8 were evaluated and are shown in Table 11:

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="97%"> <caption> <span>Table 11: EE Healing Rate (Life-Table Analysis) in Adults with EE Treated with NEXIUM Delayed-Release Capsules or Omeprazole Delayed-Release Capsules Once Daily in Four Clinical Studies</span> </caption> <colgroup> <col width="14.82%"/> <col width="11.14%"/> <col width="23.32%"/> <col width="17.22%"/> <col width="17.24%"/> <col width="16.24%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle"><span class="Bold">Study</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">No. of Patients</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">Treatment Group</span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">EE Healing Rates</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">Significance Level<span class="Italics"><span class="Sup">1</span></span></span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Week 4</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Week 8</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">1<br/> </td><td align="center" class="Rrule" valign="middle">588<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">68.7%<br/> </td><td align="center" class="Rrule" valign="middle">90.6%<br/> </td><td align="center" class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">588<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">69.5%<br/> </td><td align="center" class="Rrule" valign="middle">88.3%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">2<br/> </td><td align="center" class="Rrule" valign="middle">654<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">75.9%<br/> </td><td align="center" class="Rrule" valign="middle">94.1%<br/> </td><td align="center" class="Rrule" valign="middle">p &lt; 0.001<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">656<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">70.5%<br/> </td><td align="center" class="Rrule" valign="middle">89.9%<br/> </td><td align="center" class="Rrule" valign="middle">p &lt; 0.05<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">650<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.7%<br/> </td><td align="center" class="Rrule" valign="middle">86.9%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">3<br/> </td><td align="center" class="Rrule" valign="middle">576<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">71.5%<br/> </td><td align="center" class="Rrule" valign="middle">92.2%<br/> </td><td align="center" class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">572<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">68.6%<br/> </td><td align="center" class="Rrule" valign="middle">89.8%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">4<br/> </td><td align="center" class="Rrule" valign="middle">1216<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">81.7%<br/> </td><td align="center" class="Rrule" valign="middle">93.7%<br/> </td><td align="center" class="Rrule" valign="middle">p &lt; 0.001<br/> </td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">1209<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">68.7%<br/> </td><td align="center" class="Rrule" valign="middle">84.2%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> </tbody> </table></div>

N.S.= not significant (p > 0.05)

1. log-rank test vs. omeprazole 20 mg

In these same studies of patients with EE, sustained heartburn resolution and time to sustained heartburn resolution were evaluated and are shown in Table 12:

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="98%"> <caption> <span>Table 12: Sustained Resolution<span class="Sup">1</span> of Heartburn in Adults with EE Treated with NEXIUM Delayed-Release Capsules or Omeprazole Delayed-Release Capsules Once Daily in Four Clinical Studies</span> </caption> <colgroup> <col width="8.8%"/> <col width="16.96%"/> <col width="23.08%"/> <col width="17.06%"/> <col width="17.08%"/> <col width="17.04%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle"><span class="Bold">Study</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">No. of Patients</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">Treatment Group</span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">Cumulative Percent<span class="Italics"><span class="Sup">2</span></span> with Sustained Resolution</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">Significance Level<span class="Italics"><span class="Sup">3</span></span></span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Day 14</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Day 28</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">1<br/> </td><td align="center" class="Rrule" valign="middle">573<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.3%<br/> </td><td align="center" class="Rrule" valign="middle">72.7%<br/> </td><td align="center" class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">555<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.1%<br/> </td><td align="center" class="Rrule" valign="middle">70.9%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">2<br/> </td><td align="center" class="Rrule" valign="middle">621<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.8%<br/> </td><td align="center" class="Rrule" valign="middle">74.2%<br/> </td><td align="center" class="Rrule" valign="middle">p &lt;0.001<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">620<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">62.9%<br/> </td><td align="center" class="Rrule" valign="middle">70.1%<br/> </td><td align="center" class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">626<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">56.5%<br/> </td><td align="center" class="Rrule" valign="middle">66.6%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">3<br/> </td><td align="center" class="Rrule" valign="middle">568<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">65.4%<br/> </td><td align="center" class="Rrule" valign="middle">73.9%<br/> </td><td align="center" class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">551<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">65.5%<br/> </td><td align="center" class="Rrule" valign="middle">73.1%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">4<br/> </td><td align="center" class="Rrule" valign="middle">1187<br/> </td><td align="center" class="Rrule" valign="middle">NEXIUM 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">67.6%<br/> </td><td align="center" class="Rrule" valign="middle">75.1%<br/> </td><td align="center" class="Rrule" valign="middle">p &lt;0.001<br/> </td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">1188<br/> </td><td align="center" class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">62.5%<br/> </td><td align="center" class="Rrule" valign="middle">70.8%<br/> </td><td align="center" class="Rrule" valign="middle"> <br/> </td> </tr> </tbody> </table></div>

  1. Defined as 7 consecutive days with no heartburn reported in daily patient diary.   2. Defined as the cumulative proportion of patients who have reached the start of sustained resolution.   3. log-rank test vs. omeprazole 20 mg.N.S. = not significant (p > 0.05)

In these four studies, the range of median days to the start of sustained resolution (defined as 7 consecutive days with no heartburn) was 5 days for NEXIUM 40 mg, 7 to 8 days for NEXIUM 20 mg and 7 to 9 days for omeprazole 20 mg.

There are no comparisons of 40 mg of NEXIUM with 40 mg of omeprazole in clinical trials assessing either healing or symptomatic relief of EE.

Two multicenter, randomized, double-blind placebo-controlled 4-arm studies were conducted in adult patients with endoscopically confirmed, healed EE to evaluate NEXIUM delayed-release capsules 40 mg (n=174), 20 mg (n=180), 10 mg (n=168) or placebo (n=171) once daily over six months of treatment.

No additional clinical benefit was seen with NEXIUM 40 mg over NEXIUM 20 mg. NEXIUM 40 mg once daily is not a recommended regimen for the maintenance of healing of EE in adults.

The percentages of patients that maintained healing of EE at the various time points are shown in the Figures 2 and 3:

Figure 2: Maintenance of Healing Rates of EE in Adults by Month (Study 177)

s= scheduled visit

Figure 3: Maintenance of EE Healing Rates in Adults by Month (Study 178)

s= scheduled visit

Patients remained in remission significantly longer and the number of recurrences of EE was significantly less in patients treated with NEXIUM compared to placebo.

In both studies, the proportion of patients on NEXIUM who remained in remission and were free of heartburn and other GERD symptoms was well differentiated from placebo.

In a third multicenter open label study of 808 patients treated for 12 months with NEXIUM 40 mg, the percentage of patients that maintained healing of EE was 93.7% for six months and 89.4% for one year.

Two multicenter, randomized, double-blind, placebo-controlled studies were conducted in a total of 717 adult patients comparing four weeks of treatment with NEXIUM delayed-release capsules 20 mg or 40 mg once daily versus placebo for resolution of GERD symptoms. Patients had at least a 6-month history of heartburn episodes, no EE by endoscopy, and heartburn on at least four of the seven days immediately preceding randomization.

The percentage of patients that were symptom-free of heartburn was significantly higher in the NEXIUM groups compared to placebo at all follow-up visits (Weeks 1, 2, and 4).

No additional clinical benefit was seen with NEXIUM 40 mg over NEXIUM 20 mg. NEXIUM 40 mg once daily is not a recommended regimen for the treatment of symptomatic GERD in adults.

The percent of patients symptom-free of heartburn by day are shown in the Figures 4 and 5:

Figure 4: Percent of Patients Symptom-Free of Heartburn by Day (Study 225)

Figure 5: Percent of Patients Symptom-Free of Heartburn by Day (Study 226)

In three European symptomatic GERD trials, NEXIUM 20 mg and 40 mg and omeprazole 20 mg were evaluated. No significant treatment related differences were seen.

1 Year to 11 Years of Age

In a multicenter, parallel-group study, 109 pediatric patients with a history of endoscopically-proven GERD (1 year to 11 years of age; 53 female; 89 Caucasian, 19 Black, 1 Other) were treated with esomeprazole magnesium for delayed-release oral suspension once daily for up to 8 weeks to evaluate safety and tolerability. Dosing by patient weight was as follows:

Patients were endoscopically characterized as to the presence or absence of EE.

Of the 109 patients, 53 had EE at baseline (51 had mild, 1 moderate, and 1 severe esophagitis). Although most of the patients who had a follow up endoscopy at the end of 8 weeks of treatment healed, spontaneous healing cannot be ruled out because these patients had low grade EE prior to treatment, and the trial did not include a concomitant control.

12 Years to 17 Years of Age

In a multicenter, randomized, double-blind, parallel-group study, 149 adolescent patients (12 to 17 years of age; 89 female; 124 Caucasian, 15 Black, 10 Other) with clinically diagnosed GERD were treated with NEXIUM delayed-release capsules 20 mg or 40 mg once daily for up to 8 weeks to evaluate safety and tolerability. Patients were not endoscopically characterized as to the presence or absence of EE.

Two multicenter, double-blind, placebo-controlled studies were conducted in adult patients at risk of developing gastric and/or duodenal ulcers associated with continuous use of non-selective and COX-2 selective NSAIDs. A total of 1429 patients were randomized across the 2 studies. Patients ranged in age from 19 to 89 (median age 66 years) with 71% female, 29% male; 83% Caucasian, 5% Black, 4% Asian, and 8% Others. At baseline, the patients in these studies were endoscopically confirmed not to have ulcers but were determined to be at risk for ulcer occurrence due to their age (at least 60 years) and/or history of a documented gastric or duodenal ulcer within the past 5 years. Patients receiving NSAIDs and treated with NEXIUM delayed-release capsules 20 mg or 40 mg once daily experienced significant reduction in gastric ulcer occurrences relative to placebo treatment at 26 weeks. See Table 13. No additional benefit was seen with NEXIUM 40 mg over NEXIUM 20 mg. NEXIUM 40 mg once daily is not a recommended regimen for the risk reduction of NSAID-associated gastric ulcer in adults. These studies did not demonstrate significant reduction in the development of NSAID-associated duodenal ulcer due to the low incidence.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 13: Cumulative Percentage of Patients at Least 60 Years of Age Taking NSAIDS Without Gastric Ulcers at 26 Weeks in Two Randomized Placebo-Controlled Studies</span> </caption> <colgroup> <col width="14%"/> <col width="21%"/> <col width="35%"/> <col width="28%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle">Study<br/> </td><td class="Rrule" valign="middle">No. of Patients<br/> </td><td class="Rrule" valign="middle">Treatment Group<br/> </td><td class="Rrule" valign="middle">% of Patients Remaining Gastric Ulcer Free<span class="Italics"><span class="Sup"> 1</span></span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">1<br/> </td><td class="Rrule" valign="top">191<br/> <br/>194<br/> <br/>184<br/> <br/> </td><td class="Rrule" valign="top">NEXIUM 20 mg<br/>NEXIUM 40 mg<br/>Placebo<br/> </td><td class="Rrule" valign="top">95.4<br/> <br/>96.7<br/> <br/>88.2<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top">2<br/> </td><td class="Rrule" valign="top">267<br/> <br/>271<br/> <br/>257<br/> </td><td class="Rrule" valign="top">NEXIUM 20 mg<br/>NEXIUM 40 mg<br/>Placebo<br/> </td><td class="Rrule" valign="top">94.7<br/> <br/>95.3<br/> <br/>83.3<br/> </td> </tr> </tbody> </table></div>

1. %= Life Table Estimate. Significant difference from placebo (p<0.01).

Two multicenter, randomized, double-blind studies were conducted in adult patients using a 10-day treatment regimen of triple therapy (NEXIUM, amoxicillin and clarithromycin). The first study (191) compared NEXIUM delayed-release capsules 40 mg once daily in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily to NEXIUM delayed-release capsules 40 mg once daily plus clarithromycin 500 mg twice daily. The second study (193) compared NEXIUM delayed-release capsules 40 mg once daily in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily to NEXIUM delayed-release capsules 40 mg once daily. H. pylori eradication rates, defined as at least two negative tests and no positive tests from CLOtest®, histology and/or culture, at 4 weeks post-therapy were significantly higher in the NEXIUM, amoxicillin and clarithromycin group than in the NEXIUM and clarithromycin group or the NEXIUM alone group. The results are shown in Table 14:

Table 14: H. pylori Eradication Rates at 4 Weeks after 10 Day Treatment Regimen % of Adult Patients Cured [95% Confidence Interval] (Number of Patients)

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <colgroup> <col width="10%"/> <col width="42%"/> <col width="26%"/> <col width="20%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle">Study<br/> </td><td class="Rrule" valign="middle">Treatment Group<br/> </td><td align="center" class="Rrule" valign="middle">Per-Protocol<span class="Italics"><span class="Sup">1</span></span> <br/> </td><td align="center" class="Rrule" valign="middle">Intent-to-Treat<span class="Italics"><span class="Sup">2</span></span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">191<br/> </td><td class="Rrule" valign="top">NEXIUM, amoxicillin and clarithromycin<br/> </td><td align="center" class="Rrule" valign="top">84%<span class="Italics"><span class="Sup">3</span></span> <br/>[78, 89]<br/> (n=196)<br/> </td><td align="center" class="Rrule" valign="top">77%<span class="Italics"><span class="Sup">3</span></span> <br/>[71, 82]<br/>(n=233)<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"> <br/> </td><td class="Rrule" valign="top">NEXIUM and clarithromycin<br/> </td><td align="center" class="Rrule" valign="top">55%<br/>[48, 62]<br/>(n=187)<br/> </td><td align="center" class="Rrule" valign="top">52%<br/>[45, 59]<br/>(n=215)<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">193 <br/> </td><td class="Rrule" valign="top">NEXIUM, amoxicillin and clarithromycin<br/> </td><td align="center" class="Rrule" valign="top">85%<span class="Italics"><span class="Sup">4</span></span> <br/>[74, 93]<br/>(n=67)<br/> </td><td align="center" class="Rrule" valign="top">78%<span class="Italics"><span class="Sup">4</span></span> <br/>[67, 87]<br/>(n=74)<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top"> <br/> </td><td class="Rrule" valign="top">NEXIUM<br/> <br/> </td><td align="center" class="Rrule" valign="top">5%<br/>[0, 23]<br/>(n=22)<br/> </td><td align="center" class="Rrule" valign="top">4%<br/>[0, 21]<br/>(n=24)<br/> </td> </tr> </tbody> </table></div>

1.    Patients were included in the analysis if they had H. pylori infection documented at baseline, had at least one endoscopically verified duodenal ulcer ≥ 0.5 cm in diameter at baseline or had a documented history of duodenal ulcer disease within the past 5 years, and were not protocol violators. Patients who dropped out of the study due to an adverse reaction related to the study drug were included in the analysis as not H. pylori eradicated.

2.    Patients were included in the analysis if they had documented H. pylori infection at baseline, had at least one documented duodenal ulcer at baseline, or had a documented history of duodenal ulcer disease, and took at least one dose of study medication. All dropouts were included as not H. pylori eradicated.

3.  p < 0.05 compared to NEXIUM plus clarithromycin.

4.  p < 0.05 compared to NEXIUM alone.

The percentage of patients with a healed baseline duodenal ulcer by 4 weeks after the 10-day treatment regimen in the NEXIUM, amoxicillin and clarithromycin group was 75% (n=156) and 57% (n=60) respectively, in the 191 and 193 studies (per-protocol analysis).

In a multicenter, open-label dose-escalation study of 21 adult patients (15 males and 6 females, 18 Caucasian and 3 Black, mean age of 56 years) with pathological hypersecretory conditions, such as Zollinger-Ellison Syndrome, NEXIUM significantly inhibited gastric acid secretion. The initial dosage of NEXIUM delayed-release capsules was 40 mg twice daily in 19 patients and 80 mg twice daily in 2 patients. Total daily doses ranging from 80 mg to 240 mg for 12 months maintained gastric acid output below the target levels of 10 mEq/h in patients without prior gastric acid-reducing surgery and below 5 mEq/hr in patients with prior gastric acid-reducing surgery. At the Month 12 final visit, 18/20 (90%) patients had Basal Acid Output (BAO) under satisfactory control (median BAO = 0.17 mmol/hr). Of the 18 patients evaluated with a starting dose of NEXIUM 40 mg twice daily, 13 (72%) had their BAO controlled with the original dosing regimen at the final visit. See Table 15.

Table 15: Adequate Acid Suppression at Final Visit by Dosage Regimen in Adult Patients with Pathological Hypersecretory Conditions

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <colgroup> <col width="50%"/> <col width="50%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="top"><span class="Bold">NEXIUM </span><span class="Bold">dose at the Month 12 visit</span> <br/> </td><td class="Rrule" valign="top"><span class="Bold">BAO under adequate control at the Month 12 visit (N=20)<span class="Italics"><span class="Sup">1</span></span></span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">40 mg twice daily<br/> </td><td class="Rrule" valign="top">13/15<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">80 mg twice daily<br/> </td><td class="Rrule" valign="top">4/4<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top">80 mg three times daily      <br/> </td><td class="Rrule" valign="top">1/1<br/> </td> </tr> </tbody> </table></div>

1. One patient was not evaluated.

Esomeprazole magnesium for delayed-release oral suspension is supplied as a unit dose packet containing a fine yellow powder, consisting of white to off white spherical esomeprazole delayed-release granules and pale yellow inactive granules. Esomeprazole magnesium for delayed-release oral suspension unit dose packets are supplied as follows:

{ "type": "p", "children": [], "text": "Esomeprazole magnesium for delayed-release oral suspension is supplied as a unit dose packet containing a fine yellow powder, consisting of white to off white spherical esomeprazole delayed-release granules and pale yellow inactive granules. Esomeprazole magnesium for delayed-release oral suspension unit dose packets are supplied as follows: " }

NDC 59651-803-30 unit dose packages of 30: 10 mg esomeprazole packets

{ "type": "p", "children": [], "text": "NDC 59651-803-30 unit dose packages of 30: 10 mg esomeprazole packets " }

Store at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F) [See USP Controlled Room Temperature].

{ "type": "p", "children": [], "text": "Store at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F) [See USP Controlled Room Temperature]." }

Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use).

{ "type": "p", "children": [], "text": "Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use). " }

Acute Tubulointerstitial Nephritis

{ "type": "p", "children": [], "text": "\nAcute Tubulointerstitial Nephritis \n" }

Advise the patient or caregiver to call the patient’s healthcare provider immediately if they experience signs and/or symptoms associated with suspected acute TIN [see Warnings and Precautions (5.2)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to call the patient’s healthcare provider immediately if they experience signs and/or symptoms associated with suspected acute TIN [see Warnings and Precautions (5.2)]. \n" }

Clostridium difficile-Associated Diarrhea

{ "type": "p", "children": [], "text": "\nClostridium difficile-Associated Diarrhea \n" }

Advise the patient or caregiver to immediately call the patient’s healthcare provider if they experience diarrhea that does not improve [see Warnings and Precautions (5.3)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to immediately call the patient’s healthcare provider if they experience diarrhea that does not improve [see Warnings and Precautions (5.3)]. \n" }

Bone Fracture

{ "type": "p", "children": [], "text": "\nBone Fracture \n" }

Advise the patient or caregiver to report any fractures, especially of the hip, wrist or spine, to the patient’s healthcare provider [see Warnings and Precautions (5.4)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any fractures, especially of the hip, wrist or spine, to the patient’s healthcare provider [see Warnings and Precautions (5.4)]. \n" }

Severe Cutaneous Adverse Reactions

{ "type": "p", "children": [], "text": "\nSevere Cutaneous Adverse Reactions\n" }

Advise the patient or caregiver to discontinue esomeprazole magnesium and immediately call the patient’s healthcare provider for at first appearance of a severe cutaneous adverse reaction or other sign of hypersensitivity signs or symptoms associated with Severe Cutaneous Adverse Reactions [see Warnings and Precautions (5.5)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to discontinue esomeprazole magnesium and immediately call the patient’s healthcare provider for at first appearance of a severe cutaneous adverse reaction or other sign of hypersensitivity signs or symptoms associated with Severe Cutaneous Adverse Reactions [see Warnings and Precautions (5.5)].\n" }

Cutaneous and Systemic Lupus Erythematosus

{ "type": "p", "children": [], "text": "\nCutaneous and Systemic Lupus Erythematosus \n" }

Advise the patient or caregiver to immediately call the patient’s healthcare provider for any new or worsening of symptoms associated with cutaneous or systemic lupus erythematosus [see Warnings and Precautions (5.6)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to immediately call the patient’s healthcare provider for any new or worsening of symptoms associated with cutaneous or systemic lupus erythematosus [see Warnings and Precautions (5.6)].\n" }

Cyanocobalamin (Vitamin B-12) Deficiency

{ "type": "p", "children": [], "text": "\nCyanocobalamin (Vitamin B-12) Deficiency \n" }

Advise the patient or caregiver to report any clinical symptoms that may be associated with cyanocobalamin deficiency to the patient’s healthcare provider if they have been receiving esomeprazole magnesium for longer than 3 years [see Warnings and Precautions (5.8)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any clinical symptoms that may be associated with cyanocobalamin deficiency to the patient’s healthcare provider if they have been receiving esomeprazole magnesium for longer than 3 years [see Warnings and Precautions (5.8)]. \n" }

Hypomagnesemia and Mineral Metabolism

{ "type": "p", "children": [], "text": "\nHypomagnesemia and Mineral Metabolism \n" }

Advise the patient or caregiver to report any clinical symptoms that may be associated with hypomagnesemia, hypocalcemia, and/or hypokalemia to the patient’s healthcare provider, if they have been receiving esomeprazole magnesium for at least 3 months [see Warnings and Precautions (5.9)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any clinical symptoms that may be associated with hypomagnesemia, hypocalcemia, and/or hypokalemia to the patient’s healthcare provider, if they have been receiving esomeprazole magnesium for at least 3 months [see Warnings and Precautions (5.9)]. \n" }

Drug Interactions

{ "type": "p", "children": [], "text": "\nDrug Interactions \n" }

Advise the patient or caregiver to report to their healthcare provider if starting treatment with rilpivirine-containing products, clopidogrel, St. John’s Wort or rifampin; or, if they take high-dose methotrexate [see Contraindications (4), Warnings and Precautions (5.7, 5.10, 5.12)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report to their healthcare provider if starting treatment with rilpivirine-containing products, clopidogrel, St. John’s Wort or rifampin; or, if they take high-dose methotrexate [see Contraindications (4), Warnings and Precautions (5.7, 5.10, 5.12)]. \n" }

Administration

{ "type": "p", "children": [], "text": "\nAdministration \n" }

{ "type": "ul", "children": [ "Take esomeprazole magnesium for delayed-release oral suspension at least one hour before meals. ", "Antacids may be used concomitantly with esomeprazole magnesium.", "Administer esomeprazole magnesium for delayed-release oral suspension orally or via a nasogastric or gastric tube, as described in the Instructions for Use.  \n" ], "text": "" }

Dispense with Medication Guide available at: www.aurobindousa.com/medication-guides

{ "type": "p", "children": [], "text": "\nDispense with Medication Guide available at: www.aurobindousa.com/medication-guides\n" }

Distributed by: Aurobindo Pharma USA, Inc. 279 Princeton-Hightstown Road East Windsor, NJ 08520

{ "type": "p", "children": [], "text": "Distributed by:\nAurobindo Pharma USA, Inc.\n 279 Princeton-Hightstown Road East Windsor, NJ 08520 " }

Manufactured by: Aurobindo Pharma Limited Hyderabad-500 032, India The brands listed are trademarks of their respective owners and are not trademarks of Aurobindo Pharma Limited.

{ "type": "p", "children": [], "text": "Manufactured by:\nAurobindo Pharma Limited\n Hyderabad-500 032, India\n The brands listed are trademarks of their respective owners and are not trademarks of Aurobindo Pharma Limited." }

Revised: 09/2024

{ "type": "p", "children": [], "text": "Revised: 09/2024" }

Dispense with Medication Guide available at: www.aurobindousa.com/medication-guides

{ "type": "p", "children": [], "text": "\nDispense with Medication Guide available at: www.aurobindousa.com/medication-guides\n" }

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <colgroup> <col width="100%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" valign="top"><span class="Bold">MEDICATION GUIDE</span> <br/> <span class="Bold">Esomeprazole Magnesium <span class="Bold">(es’’ oh mep’ ra zole mag nee’ zee um)<br/> </span>For Delayed-Release Oral Suspension </span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension? </span> <br/> <span class="Bold"> Esomeprazole magnesium for delayed-release oral suspension may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor. </span> <br/> <span class="Bold">Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including: </span> <br/> <ul class="Disc"> <li> <span class="Bold">A type of kidney problem (acute tubulointerstitial nephritis)</span>. Some people who take proton pump inhibitor (PPI) medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop a kidney problem called acute tubulointerstitial nephritis that can happen at any time during treatment with esomeprazole magnesium for delayed-release oral suspension. Call your doctor right away if you have a decrease in the amount that you urinate or if you have blood in your urine. </li> <li> <span class="Bold">Diarrhea caused by an infection (<span class="Italics">Clostridium difficile</span>) in your intestines</span>. Call your doctor right away if you have watery stools or stomach pain that does not go away. You may or may not have a fever. </li> <li> <span class="Bold">Bone fractures (hip, wrist, or spine)</span>. Bone fractures in the hip, wrist, or spine may happen in people who take multiple daily doses of PPI medicines and for a long period of time (a year or longer). Tell your doctor if you have a bone fracture, especially in the hip, wrist, or spine. </li> <li> <span class="Bold">Certain types of lupus erythematosus</span>. Lupus erythematosus is an autoimmune disorder (the body’s immune cells attack other cells or organs in the body). Some people who take PPI medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop certain types of lupus erythematosus or have worsening of the lupus they already have. Call your doctor right away if you have new or worsening joint pain or a rash on your cheeks or arms that gets worse in the sun.</li> </ul> Talk to your doctor about your risk of these serious side effects. <br/>Esomeprazole magnesium for delayed-release oral suspension can have other serious side effects. See “<span class="Bold">What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension?”</span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">What is esomeprazole magnesium for delayed-release oral suspension? </span> <br/>A prescription medicine called a proton pump inhibitor (PPI) used to reduce the amount of acid in your stomach. <br/>Esomeprazole magnesium for delayed-release oral suspension is used in adults for: <br/> <ul class="Disc"> <li>4 to 8 weeks for the healing and symptom relief of acid-related damage to the esophagus (erosive esophagitis or EE). Your doctor may prescribe another 4-8 weeks of esomeprazole magnesium for delayed-release oral suspension in patients whose EE does not heal. </li> <li>maintaining healing of EE. </li> <li>4 to 8 weeks to treat heartburn and other symptoms that happen with gastroesophageal reflux disease (GERD). </li> <li>up to 6 months to reduce the risk of stomach ulcers in some people taking pain medicines called non-steroidal anti-inflammatory drugs (NSAIDs). </li> <li>treating patients with a stomach infection (<span class="Italics">Helicobacter pylori</span>) and a stomach ulcer, along with the antibiotics amoxicillin and clarithromycin. </li> <li>the long-term treatment of conditions where your stomach makes too much acid, including Zollinger-Ellison Syndrome. Zollinger-Ellison Syndrome is a rare condition in which the stomach produces a more than normal amount of acid. </li> </ul>Esomeprazole magnesium for delayed-release oral suspension is used in children and adolescents 12 to 17 years of age for: <br/> <ul class="Disc"> <li>4 to 8 weeks to heal EE. </li> <li>4 weeks to treat heartburn and other symptoms that happen with GERD. </li> </ul>Esomeprazole magnesium for delayed-release oral suspension is used in children 1 to 11 years of age for: <br/> <ul class="Disc"> <li>8 weeks to heal EE. </li> <li>up to 8 weeks to treat heartburn and other symptoms that happen with GERD. </li> </ul>Esomeprazole magnesium for delayed-release oral suspension is used in children 1 month to less than 1 year of age to treat GERD with EE for up to 6 weeks. <br/>It is not known if esomeprazole magnesium for delayed-release oral suspension is safe and effective in children under 1 month of age for the treatment of GERD with EE. <br/>It is not known if esomeprazole magnesium for delayed-release oral suspension is safe and effective in children less than 1 year of age for the treatment of GERD symptoms. <br/>It is not known if esomeprazole magnesium for delayed-release oral suspension is safe and effective in children to reduce the risk of stomach ulcers in children who take medicines called NSAIDs, to treat <span class="Italics">Helicobacter pylori </span>stomach infection to lower the risk of a stomach ulcer returning, and to treat conditions where your stomach makes too much acid. <span class="Bold"></span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">Do not take esomeprazole magnesium for delayed-release oral suspension if you are: </span> <br/> <ul class="Disc"> <li>allergic to esomeprazole magnesium, any other PPI medicine, or any of the ingredients in esomeprazole magnesium for delayed-release oral suspension. See the end of this Medication Guide for a complete list of ingredients in esomeprazole magnesium for delayed-release oral suspension. </li> </ul>Tell your doctor right away or get emergency medical help if you get any of the following symptoms of an allergic reaction with esomeprazole magnesium for delayed-release oral suspension:<br/> <br/> <ul class="Disc"> <li>rash</li> <li>face swelling</li> <li>throat tightness</li> <li>difficulty breathing</li> </ul> <br/> <ul class="Disc"> <li>taking a medicine that contains rilpivirine (EDURANT, COMPLERA, ODEFSEY) used to treat HIV-1 (Human Immunodeficiency Virus). </li> </ul> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">Before taking esomeprazole magnesium for delayed-release oral suspension, tell your doctor about all of your medical conditions, including if you: </span> <br/> <ul class="Disc"> <li>have low magnesium levels, low calcium levels and low potassium levels in your blood. </li> <li>have liver problems.</li> <li>are pregnant or plan to become pregnant. It is not known if esomeprazole magnesium for delayed-release oral suspension will harm your unborn baby.</li> <li>are breastfeeding or planning to breastfeed. Esomeprazole magnesium may pass into your breast milk. Talk to your doctor about the best way to feed your baby if you take esomeprazole magnesium for delayed-release oral suspension. </li> </ul> <span class="Bold">Tell your doctor about all of the medicines you take</span>, including prescription and over-the-counter medicines, vitamins, and herbal supplements. <br/> <span class="Bold">Especially tell your doctor if you take: </span>clopidogrel (Plavix), methotrexate (Otrxup, Rasuvo, Trexall, XATMEP), digoxin (LANOXIN), rilpivirine (EDURANT), St. John’s Wort (Hypericum perforatum), or rifampin (Rimactane, Rifater, Rifamate). <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">How should I take esomeprazole magnesium for delayed-release oral suspension?</span> <br/> <span class="Bold"> </span> <br/> <ul class="Disc"> <li>Take esomeprazole magnesium for delayed-release oral suspension exactly as prescribed by your doctor. </li> <li>Do not change your dose or stop esomeprazole magnesium for delayed-release oral suspension without talking to your doctor. </li> <li>Take esomeprazole magnesium for delayed-release oral suspension at least 1 hour before a meal. </li> <li>Antacids may be taken with esomeprazole magnesium for delayed-release oral suspension. </li> <li>If you forget to take a dose of esomeprazole magnesium for delayed-release oral suspension, take it as soon as you remember. If it is almost time for your next dose, do not take the missed dose. Take the next dose on time. Do not take a double dose to make up for a missed dose. </li> <li>If you take too much esomeprazole magnesium for delayed-release oral suspension, call your doctor or local poison control center right away at 1-800-222-1222, or go to the nearest hospital emergency room. </li> <li>See the <span class="Bold">Instructions for Use </span>at the end of this Medication Guide for instructions on how to take esomeprazole magnesium for delayed-release oral suspension, and how to mix and give esomeprazole magnesium for delayed-release oral suspension through a nasogastric tube or gastric tube. </li> </ul> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension? </span> <br/> <span class="Bold"> Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including: </span> <br/> <ul class="Disc"> <li> <span class="Bold">See </span>“<span class="Bold">What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension?” </span> </li> <li> <span class="Bold">Low vitamin B-12 levels in your body </span>can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for a long time (more than 3 years). Tell your doctor if you have symptoms of low vitamin B-12 levels, including shortness of breath, lightheadedness, irregular heartbeat, muscle weakness, pale skin, feeling tired, mood changes, and tingling or numbness in the arms and legs. </li> <li> <span class="Bold">Low magnesium levels in your body </span>can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for at least 3 months. Tell your doctor right away if you have symptoms of low magnesium levels, including seizures, dizziness, irregular heartbeat, jitteriness, muscle aches or weakness, and spasms of hands, feet or voice. </li> <li> <span class="Bold">Stomach growths (fundic gland polyps). </span>People who take PPI medicines for a long time have an increased risk of developing a certain type of stomach growths called fundic gland polyps, especially after taking PPI medicines for more than 1 year. </li> <li> <span class="Bold">Severe skin reactions. </span>Esomeprazole magnesium for delayed-release oral suspension can cause rare but severe skin reactions that may affect any part of your body. These serious skin reactions may need to be treated in a hospital and may be life threatening: </li> <li>Skin rash which may have blistering, peeling or bleeding on any part of your skin (including your lips, eyes, mouth, nose, genitals, hands or feet). </li> <li>You may also have fever, chills, body aches, shortness of breath, or enlarged lymph nodes. Stop taking esomeprazole magnesium for delayed-release oral suspension and call your doctor right away. These symptoms may be the first sign of a severe skin reaction. </li> </ul> <br/>The most common side effects of esomeprazole magnesium for delayed-release oral suspension include: <br/> <ul class="Disc"> <li>   headache</li> <li>   diarrhea</li> <li>   nausea</li> <li>   gas</li> <li>   stomach (abdominal) pain</li> <li>   constipation</li> <li>   dry mouth</li> </ul>These are not all the possible side effects of esomeprazole magnesium for delayed-release oral suspension.<br/> <br/>Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">How should I store esomeprazole magnesium for delayed-release oral suspension? </span> <br/> <ul class="Disc"> <li>Store esomeprazole magnesium for delayed-release oral suspension at room temperature between 68°F to 77°F (20°C to 25°C). </li> </ul> <span class="Bold"> Keep esomeprazole magnesium for delayed-release oral suspension and all medicines out of the reach of children. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">General information about the safe and effective use of esomeprazole magnesium for delayed-release oral suspension. </span> <br/>Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use esomeprazole magnesium for delayed-release oral suspension for a condition for which it was not prescribed. Do not give esomeprazole magnesium for delayed-release oral suspension to other people, even if they have the same symptoms you have. It may harm them. <br/> <br/>You can ask your pharmacist or doctor for information about esomeprazole magnesium for delayed-release oral suspension that is written for health professionals. <br/> </td> </tr> <tr class="Last"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold"> What are the ingredients in esomeprazole magnesium for delayed-release oral suspension? </span> <br/> <span class="Bold"> Active ingredient: </span>esomeprazole magnesium trihydrate <br/> <br/> <span class="Bold">Inactive </span><span class="Bold">ingredients in enteric coated granules: </span>hydroxypropyl cellulose, hypromellose, magnesium carbonate, magnesium oxide, methacrylic acid and ethyl acrylate copolymer dispersion (contains copolymer based on ethyl acrylate and methacrylic acid, polysorbate 80 and sodium lauryl sulfate), mono-and di-glycerides, polysorbate 80, sugar spheres (which contains liquid glucose, starch (maize) and sucrose), talc and triethyl citrate.<br/> <span class="Bold"> <br/> Inactive ingredients in inactive granules:</span> citric acid anhydrous, crospovidone, dextrose, ferric oxide yellow, hydroxypropyl cellulose and xanthan gum.<span class="Bold"></span> <br/> <br/>The brands listed are trademarks of their respective owners and are not trademarks of Aurobindo Pharma Limited.<br/> <br/> Distributed by:<br/> <span class="Bold"> Aurobindo Pharma USA, Inc.</span> <br/>279 Princeton-Hightstown Road<br/>East Windsor, NJ 08520 <br/> <br/>Manufactured by:<br/> <span class="Bold">Aurobindo Pharma Limited</span> <br/>Hyderabad-500 032, India<br/> <br/>For more information, call Aurobindo Pharma USA, Inc. at 1-866-850-2876. <br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\">\n<colgroup>\n<col width=\"100%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First\">\n<td align=\"center\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">MEDICATION GUIDE</span>\n<br/>\n<span class=\"Bold\">Esomeprazole Magnesium <span class=\"Bold\">(es’’ oh mep’ ra zole mag nee’ zee um)<br/>\n</span>For Delayed-Release Oral Suspension </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension? </span>\n<br/>\n<span class=\"Bold\"> Esomeprazole magnesium for delayed-release oral suspension may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor. </span>\n<br/>\n<span class=\"Bold\">Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including: </span>\n<br/>\n<ul class=\"Disc\">\n<li>\n<span class=\"Bold\">A type of kidney problem (acute tubulointerstitial nephritis)</span>. Some people who take proton pump inhibitor (PPI) medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop a kidney problem called acute tubulointerstitial nephritis that can happen at any time during treatment with esomeprazole magnesium for delayed-release oral suspension. Call your doctor right away if you have a decrease in the amount that you urinate or if you have blood in your urine. </li>\n<li>\n<span class=\"Bold\">Diarrhea caused by an infection (<span class=\"Italics\">Clostridium difficile</span>) in your intestines</span>. Call your doctor right away if you have watery stools or stomach pain that does not go away. You may or may not have a fever. </li>\n<li>\n<span class=\"Bold\">Bone fractures (hip, wrist, or spine)</span>. Bone fractures in the hip, wrist, or spine may happen in people who take multiple daily doses of PPI medicines and for a long period of time (a year or longer). Tell your doctor if you have a bone fracture, especially in the hip, wrist, or spine. </li>\n<li>\n<span class=\"Bold\">Certain types of lupus erythematosus</span>. Lupus erythematosus is an autoimmune disorder (the body’s immune cells attack other cells or organs in the body). Some people who take PPI medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop certain types of lupus erythematosus or have worsening of the lupus they already have. Call your doctor right away if you have new or worsening joint pain or a rash on your cheeks or arms that gets worse in the sun.</li>\n</ul> Talk to your doctor about your risk of these serious side effects. <br/>Esomeprazole magnesium for delayed-release oral suspension can have other serious side effects. See “<span class=\"Bold\">What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension?”</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">What is esomeprazole magnesium for delayed-release oral suspension? </span>\n<br/>A prescription medicine called a proton pump inhibitor (PPI) used to reduce the amount of acid in your stomach. <br/>Esomeprazole magnesium for delayed-release oral suspension is used in adults for: <br/>\n<ul class=\"Disc\">\n<li>4 to 8 weeks for the healing and symptom relief of acid-related damage to the esophagus (erosive esophagitis or EE). Your doctor may prescribe another 4-8 weeks of esomeprazole magnesium for delayed-release oral suspension in patients whose EE does not heal. </li>\n<li>maintaining healing of EE. </li>\n<li>4 to 8 weeks to treat heartburn and other symptoms that happen with gastroesophageal reflux disease (GERD). </li>\n<li>up to 6 months to reduce the risk of stomach ulcers in some people taking pain medicines called non-steroidal anti-inflammatory drugs (NSAIDs). </li>\n<li>treating patients with a stomach infection (<span class=\"Italics\">Helicobacter pylori</span>) and a stomach ulcer, along with the antibiotics amoxicillin and clarithromycin. </li>\n<li>the long-term treatment of conditions where your stomach makes too much acid, including Zollinger-Ellison Syndrome. Zollinger-Ellison Syndrome is a rare condition in which the stomach produces a more than normal amount of acid. </li>\n</ul>Esomeprazole magnesium for delayed-release oral suspension is used in children and adolescents 12 to 17 years of age for: <br/>\n<ul class=\"Disc\">\n<li>4 to 8 weeks to heal EE. </li>\n<li>4 weeks to treat heartburn and other symptoms that happen with GERD. </li>\n</ul>Esomeprazole magnesium for delayed-release oral suspension is used in children 1 to 11 years of age for: <br/>\n<ul class=\"Disc\">\n<li>8 weeks to heal EE. </li>\n<li>up to 8 weeks to treat heartburn and other symptoms that happen with GERD. </li>\n</ul>Esomeprazole magnesium for delayed-release oral suspension is used in children 1 month to less than 1 year of age to treat GERD with EE for up to 6 weeks. <br/>It is not known if esomeprazole magnesium for delayed-release oral suspension is safe and effective in children under 1 month of age for the treatment of GERD with EE. <br/>It is not known if esomeprazole magnesium for delayed-release oral suspension is safe and effective in children less than 1 year of age for the treatment of GERD symptoms. <br/>It is not known if esomeprazole magnesium for delayed-release oral suspension is safe and effective in children to reduce the risk of stomach ulcers in children who take medicines called NSAIDs, to treat <span class=\"Italics\">Helicobacter pylori </span>stomach infection to lower the risk of a stomach ulcer returning, and to treat conditions where your stomach makes too much acid. <span class=\"Bold\"></span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">Do not take esomeprazole magnesium for delayed-release oral suspension if you are: </span>\n<br/>\n<ul class=\"Disc\">\n<li>allergic to esomeprazole magnesium, any other PPI medicine, or any of the ingredients in esomeprazole magnesium for delayed-release oral suspension. See the end of this Medication Guide for a complete list of ingredients in esomeprazole magnesium for delayed-release oral suspension. </li>\n</ul>Tell your doctor right away or get emergency medical help if you get any of the following symptoms of an allergic reaction with esomeprazole magnesium for delayed-release oral suspension:<br/> <br/>\n<ul class=\"Disc\">\n<li>rash</li>\n<li>face swelling</li>\n<li>throat tightness</li>\n<li>difficulty breathing</li>\n</ul> <br/>\n<ul class=\"Disc\">\n<li>taking a medicine that contains rilpivirine (EDURANT, COMPLERA, ODEFSEY) used to treat HIV-1 (Human Immunodeficiency Virus). </li>\n</ul>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">Before taking esomeprazole magnesium for delayed-release oral suspension, tell your doctor about all of your medical conditions, including if you: </span>\n<br/>\n<ul class=\"Disc\">\n<li>have low magnesium levels, low calcium levels and low potassium levels in your blood. </li>\n<li>have liver problems.</li>\n<li>are pregnant or plan to become pregnant. It is not known if esomeprazole magnesium for delayed-release oral suspension will harm your unborn baby.</li>\n<li>are breastfeeding or planning to breastfeed. Esomeprazole magnesium may pass into your breast milk. Talk to your doctor about the best way to feed your baby if you take esomeprazole magnesium for delayed-release oral suspension. </li>\n</ul>\n<span class=\"Bold\">Tell your doctor about all of the medicines you take</span>, including prescription and over-the-counter medicines, vitamins, and herbal supplements. <br/>\n<span class=\"Bold\">Especially tell your doctor if you take: </span>clopidogrel (Plavix), methotrexate (Otrxup, Rasuvo, Trexall, XATMEP), digoxin (LANOXIN), rilpivirine (EDURANT), St. John’s Wort (Hypericum perforatum), or rifampin (Rimactane, Rifater, Rifamate). <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">How should I take esomeprazole magnesium for delayed-release oral suspension?</span>\n<br/>\n<span class=\"Bold\"> </span>\n<br/>\n<ul class=\"Disc\">\n<li>Take esomeprazole magnesium for delayed-release oral suspension exactly as prescribed by your doctor. </li>\n<li>Do not change your dose or stop esomeprazole magnesium for delayed-release oral suspension without talking to your doctor. </li>\n<li>Take esomeprazole magnesium for delayed-release oral suspension at least 1 hour before a meal. </li>\n<li>Antacids may be taken with esomeprazole magnesium for delayed-release oral suspension. </li>\n<li>If you forget to take a dose of esomeprazole magnesium for delayed-release oral suspension, take it as soon as you remember. If it is almost time for your next dose, do not take the missed dose. Take the next dose on time. Do not take a double dose to make up for a missed dose. </li>\n<li>If you take too much esomeprazole magnesium for delayed-release oral suspension, call your doctor or local poison control center right away at 1-800-222-1222, or go to the nearest hospital emergency room. </li>\n<li>See the <span class=\"Bold\">Instructions for Use </span>at the end of this Medication Guide for instructions on how to take esomeprazole magnesium for delayed-release oral suspension, and how to mix and give esomeprazole magnesium for delayed-release oral suspension through a nasogastric tube or gastric tube. </li>\n</ul>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension? </span>\n<br/>\n<span class=\"Bold\"> Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including: </span>\n<br/>\n<ul class=\"Disc\">\n<li>\n<span class=\"Bold\">See </span>“<span class=\"Bold\">What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension?” </span>\n</li>\n<li>\n<span class=\"Bold\">Low vitamin B-12 levels in your body </span>can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for a long time (more than 3 years). Tell your doctor if you have symptoms of low vitamin B-12 levels, including shortness of breath, lightheadedness, irregular heartbeat, muscle weakness, pale skin, feeling tired, mood changes, and tingling or numbness in the arms and legs. </li>\n<li>\n<span class=\"Bold\">Low magnesium levels in your body </span>can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for at least 3 months. Tell your doctor right away if you have symptoms of low magnesium levels, including seizures, dizziness, irregular heartbeat, jitteriness, muscle aches or weakness, and spasms of hands, feet or voice. </li>\n<li>\n<span class=\"Bold\">Stomach growths (fundic gland polyps). </span>People who take PPI medicines for a long time have an increased risk of developing a certain type of stomach growths called fundic gland polyps, especially after taking PPI medicines for more than 1 year. </li>\n<li>\n<span class=\"Bold\">Severe skin reactions. </span>Esomeprazole magnesium for delayed-release oral suspension can cause rare but severe skin reactions that may affect any part of your body. These serious skin reactions may need to be treated in a hospital and may be life threatening: </li>\n<li>Skin rash which may have blistering, peeling or bleeding on any part of your skin (including your lips, eyes, mouth, nose, genitals, hands or feet). </li>\n<li>You may also have fever, chills, body aches, shortness of breath, or enlarged lymph nodes. Stop taking esomeprazole magnesium for delayed-release oral suspension and call your doctor right away. These symptoms may be the first sign of a severe skin reaction. </li>\n</ul> <br/>The most common side effects of esomeprazole magnesium for delayed-release oral suspension include: <br/>\n<ul class=\"Disc\">\n<li>   headache</li>\n<li>   diarrhea</li>\n<li>   nausea</li>\n<li>   gas</li>\n<li>   stomach (abdominal) pain</li>\n<li>   constipation</li>\n<li>   dry mouth</li>\n</ul>These are not all the possible side effects of esomeprazole magnesium for delayed-release oral suspension.<br/> <br/>Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">How should I store esomeprazole magnesium for delayed-release oral suspension? </span>\n<br/>\n<ul class=\"Disc\">\n<li>Store esomeprazole magnesium for delayed-release oral suspension at room temperature between 68°F to 77°F (20°C to 25°C). </li>\n</ul>\n<span class=\"Bold\"> Keep esomeprazole magnesium for delayed-release oral suspension and all medicines out of the reach of children. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\">General information about the safe and effective use of esomeprazole magnesium for delayed-release oral suspension. </span>\n<br/>Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use esomeprazole magnesium for delayed-release oral suspension for a condition for which it was not prescribed. Do not give esomeprazole magnesium for delayed-release oral suspension to other people, even if they have the same symptoms you have. It may harm them. <br/> <br/>You can ask your pharmacist or doctor for information about esomeprazole magnesium for delayed-release oral suspension that is written for health professionals. <br/>\n</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"justify\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> What are the ingredients in esomeprazole magnesium for delayed-release oral suspension? </span>\n<br/>\n<span class=\"Bold\"> Active ingredient: </span>esomeprazole magnesium trihydrate <br/> <br/>\n<span class=\"Bold\">Inactive </span><span class=\"Bold\">ingredients in enteric coated granules: </span>hydroxypropyl cellulose, hypromellose, magnesium carbonate, magnesium oxide, methacrylic acid and ethyl acrylate copolymer dispersion (contains copolymer based on ethyl acrylate and methacrylic acid, polysorbate 80 and sodium lauryl sulfate), mono-and di-glycerides, polysorbate 80, sugar spheres (which contains liquid glucose, starch (maize) and sucrose), talc and triethyl citrate.<br/>\n<span class=\"Bold\">\n<br/> Inactive ingredients in inactive granules:</span> citric acid anhydrous, crospovidone, dextrose, ferric oxide yellow, hydroxypropyl cellulose and xanthan gum.<span class=\"Bold\"></span>\n<br/> <br/>The brands listed are trademarks of their respective owners and are not trademarks of Aurobindo Pharma Limited.<br/>\n<br/> Distributed by:<br/>\n<span class=\"Bold\"> Aurobindo Pharma USA, Inc.</span>\n<br/>279 Princeton-Hightstown Road<br/>East Windsor, NJ 08520 <br/> <br/>Manufactured by:<br/>\n<span class=\"Bold\">Aurobindo Pharma Limited</span>\n<br/>Hyderabad-500 032, India<br/> <br/>For more information, call Aurobindo Pharma USA, Inc. at 1-866-850-2876. <br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

This Medication Guide has been approved by the U.S. Food and Drug Administration.

{ "type": "p", "children": [], "text": "This Medication Guide has been approved by the U.S. Food and Drug Administration. " }

Revised: 09/2024

{ "type": "p", "children": [], "text": "Revised: 09/2024" }

                                                                                                                                    Instructions for Use                                                                                                      Esomeprazole Magnesium (es’’ oh mep’ ra zole mag nee’ zee um)                                                                                                                              For Delayed-Release Oral Suspension

{ "type": "p", "children": [], "text": "\n                                                                                                                                    Instructions for Use                                                                                                      Esomeprazole Magnesium (es’’ oh mep’ ra zole mag nee’ zee um)                                                                                                                              For Delayed-Release Oral Suspension\n" }

Taking esomeprazole magnesium for delayed-release oral suspension in water:

{ "type": "p", "children": [], "text": "\n Taking esomeprazole magnesium for delayed-release oral suspension in water:\n" }

{ "type": "ul", "children": [ "Esomeprazole magnesium for delayed-release oral suspension comes in foil packets containing 10 mg of esomeprazole magnesium. ", "Use an oral syringe to measure the amount of water needed to mix your dose. Ask your pharmacist for an oral syringe. ", "If your prescribed dose is 10 mg, add 15 mL of water to a container. Add the contents of a foil packet containing the dose prescribed by your doctor. ", "If you or your child are instructed to use more than one foil packet for the prescribed dose, follow the mixing instructions provided by your pharmacist or doctor.", "Stir. ", "Leave the mixture for 2 to 3 minutes to thicken. ", "Stir and drink the mixture within 30 minutes. If not used within 30 minutes, throw away this dose and mix a new dose. ", "If any medicine remains in the container after drinking, add more water, stir, and drink right away. ", "For young children, you can give the dose with an oral syringe. Rinse the oral syringe with water after each use. " ], "text": "" }

Giving esomeprazole magnesium for delayed-release oral suspension with water through a nasogastric tube (NG tube) or gastric tube

{ "type": "p", "children": [], "text": "\n Giving esomeprazole magnesium for delayed-release oral suspension with water through a nasogastric tube (NG tube) or gastric tube\n" }

Esomeprazole magnesium for delayed-release oral suspension:

{ "type": "p", "children": [], "text": "Esomeprazole magnesium for delayed-release oral suspension:" }

{ "type": "ul", "children": [ "Esomeprazole magnesium for delayed-release oral suspension comes in foil packets containing 10 mg of esomeprazole magnesium.", "Use only a catheter tipped syringe to give esomeprazole magnesium for delayed-release oral suspension through a NG tube or gastric tube. ", "If your prescribed dose is 10 mg, add 15 mL of water to a catheter tipped syringe. Add the contents of a foil packet containing the dose prescribed by your doctor. ", "Shake the syringe well for 15 seconds and then leave it for 2 to 3 minutes to thicken. ", "Shake the syringe and give the medicine through the NG or gastric tube (French size 6 or larger) into the stomach within 30 minutes. ", "Refill the syringe with the same amount of water (either 5 mL or 15 mL of water depending on your dose). ", "Shake the syringe and flush any remaining medicine from the NG tube or gastric tube into the stomach. " ], "text": "" }

This Instructions for Use has been approved by the U.S. Food and Drug Administration.

{ "type": "p", "children": [], "text": "This Instructions for Use has been approved by the U.S. Food and Drug Administration." }

The brands listed are trademarks of their respective owners and are not trademarks of Aurobindo Pharma Limited.

{ "type": "p", "children": [], "text": "The brands listed are trademarks of their respective owners and are not trademarks of Aurobindo Pharma Limited." }

Distributed by: Aurobindo Pharma USA, Inc. 279 Princeton-Hightstown Road East Windsor, NJ 08520

{ "type": "p", "children": [], "text": "Distributed by:\nAurobindo Pharma USA, Inc. 279 Princeton-Hightstown Road East Windsor, NJ 08520" }

Manufactured by: Aurobindo Pharma Limited Hyderabad-500 032, India

{ "type": "p", "children": [], "text": "Manufactured by:\nAurobindo Pharma Limited\n Hyderabad-500 032, India" }

Revised: 09/2024

{ "type": "p", "children": [], "text": "Revised: 09/2024" }

Rx only                NDC 59651-803-03

{ "type": "p", "children": [], "text": "\nRx only                NDC 59651-803-03" }

Esomeprazole Magnesium For Delayed-Release Oral Suspension 10 mg*

{ "type": "p", "children": [], "text": "\nEsomeprazole Magnesium For Delayed-Release Oral Suspension 10 mg*\n\n" }

* This packet of delayed-release oral suspension contains 10 mg of esomeprazole as enteric-coated granules (equivalent to 11.1 mg esomeprazole magnesium trihydrate). Dispense the Medication Guide provided separately to each patient.

{ "type": "p", "children": [], "text": "* This packet of delayed-release oral suspension contains 10 mg of esomeprazole as enteric-coated granules (equivalent to 11.1 mg esomeprazole magnesium trihydrate).\n\n Dispense the Medication Guide provided separately to each patient.\n\n" }

Print Medication Guides at: www.aurobindousa.com/medication-guides. 

{ "type": "p", "children": [], "text": "Print Medication Guides at:\nwww.aurobindousa.com/medication-guides. \n" }

AUROBINDO

{ "type": "p", "children": [], "text": "AUROBINDO\n\n\n" }

Rx only                  NDC 59651-803-30

{ "type": "p", "children": [], "text": "\nRx only                  NDC 59651-803-30" }

Esomeprazole Magnesium For Delayed-Release Oral Suspension 10  mg*

{ "type": "p", "children": [], "text": "\nEsomeprazole Magnesium For Delayed-Release Oral Suspension 10  mg*\n\n" }

Dispense the Medication Guide provided separately to each patient.

{ "type": "p", "children": [], "text": "\nDispense the Medication Guide provided separately to each patient.\n\n" }

AUROBINDO                          30 Single Dose Packets

{ "type": "p", "children": [], "text": "\nAUROBINDO                          30 Single Dose Packets\n\n\n" }

Adults

Esomeprazole magnesium delayed-release capsules are indicated for the short-term treatment (4 to 8 weeks) in the healing and symptomatic resolution of diagnostically confirmed EE in adults. For those patients who have not healed after 4 to 8 weeks of treatment, an additional 4- to 8-week course of esomeprazole magnesium may be considered.

Pediatric Patients

12 Years to 17 Years of Age

Esomeprazole magnesium delayed-release capsules indicated for the short-term treatment (4 to 8 weeks) for the healing of EE in pediatric patients 12 years to 17 years of age. 

Esomeprazole magnesium delayed-release capsules are indicated for the maintenance of healing of EE in adults. Controlled studies do not extend beyond 6 months. 

Adults

Esomeprazole magnesium delayed-release capsules are indicated for short-term treatment (4 to 8 weeks) of heartburn and other symptoms associated with GERD in adults.

Pediatric Patients 12 Years to 17 Years of Age

Esomeprazole magnesium delayed-release capsules are indicated for short-term treatment (4 weeks) of heartburn and other symptoms associated with GERD in pediatric patients 12 years to 17 years of age. 

Esomeprazole magnesium delayed-release capsules are indicated for the reduction in the occurrence of gastric ulcers associated with continuous NSAID therapy in adult patients at risk for developing gastric ulcers. Patients are considered to be at risk due to their age (60 years and older) and/or documented history of gastric ulcers. Controlled studies do not extend beyond 6 months.

Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

Triple Therapy

Esomeprazole magnesium delayed-release capsules in combination with amoxicillin and clarithromycin is indicated for the treatment of adult patients with H. pylori infection and duodenal ulcer disease (active or history of within the past 5 years) to eradicate H. pylori.

In patients who fail therapy, susceptibility testing should be done. If resistance to clarithromycin is demonstrated or susceptibility testing is not possible, alternative antimicrobial therapy should be instituted [see Clinical Pharmacology (12.4) and the prescribing information for clarithromycin]. 

Esomeprazole magnesium delayed-release capsules are indicated for the long-term treatment of pathological hypersecretory conditions, including Zollinger-Ellison Syndrome, in adults. 

Table 1 shows the recommended adult dosage of esomeprazole magnesium by indication.

The duration of esomeprazole magnesium treatment should be based on available safety and efficacy data specific to the defined indication and dosing frequency and individual patient medical needs. Esomeprazole magnesium should only be initiated and continued if the benefits outweigh the risks of treatment.

Table 1: Recommended Dosage of esomeprazole magnesium in Adults by Indication

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="624"> <colgroup> <col width="27.8846153846154%"/> <col width="37.8205128205128%"/> <col width="34.2948717948718%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle"><span class="Bold">Adult Indication</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Recommended Dosage of esomeprazole magnesium delayed-release capsules</span></td><td class="Rrule" valign="middle"><span class="Bold">Treatment Duration</span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Healing of EE<br/> </td><td align="justify" class="Rrule" valign="top">20 mg or 40 mg<span class="Sup">1</span> once daily<br/> </td><td align="justify" class="Rrule" valign="top">4 to 8 weeks<span class="Sup">2</span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Maintenance of Healing of EE<br/> </td><td class="Rrule" valign="middle">20 mg once daily<br/> </td><td align="justify" class="Rrule" valign="top">Controlled studies do not extend beyond 6 months<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Treatment of Symptomatic GERD<br/> </td><td class="Rrule" valign="middle">20 mg once daily<br/> <br/> </td><td align="justify" class="Rrule" valign="top">4 weeks; if symptoms do not resolve completely, consider an additional 4 weeks<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Risk Reduction of NSAID-Associated Gastric Ulcer<br/> </td><td align="justify" class="Rrule" valign="top"> <br/>20 mg or 40 mg<span class="Sup">1</span> once daily<br/> </td><td align="justify" class="Rrule" valign="top">Controlled studies do not extend beyond 6 months<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" rowspan="3" valign="top"><span class="Italics">H. pylori </span>Eradication to Reduce the Risk of Duodenal Ulcer Recurrence (Triple Therapy)<br/> </td><td align="justify" class="Rrule" valign="top">Esomeprazole magnesium 40 mg once daily<span class="Sup">1</span> <br/> </td><td align="justify" class="Rrule" valign="top">10 days<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Amoxicillin 1000 mg twice daily<span class="Sup">3</span> <br/> </td><td align="justify" class="Rrule" valign="top">10 days<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Clarithromycin 500 mg twice daily<span class="Sup">3 </span> <br/> </td><td align="justify" class="Rrule" valign="top">10 days<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome<br/> </td><td align="justify" class="Rrule" valign="top">Starting dosage is 40 mg twice daily<span class="Sup">4</span>; <br/>individualize the regimen to patient needs.<br/> <br/>Dosages of up to 240 mg/day have been administered <span class="Italics">[see <span class="Underline">Clinical Studies (14.7)</span>].</span> <br/> </td><td class="Rrule" valign="middle">As long as clinically indicated<br/> </td> </tr> </tbody> </table></div>

Table 2 shows the recommended dosage of esomeprazole magnesium in pediatric patients by indication.

Table 2: Recommended Dosage of Esomeprazole Magnesium in Pediatric Patients by Indication

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="0"> <colgroup> <col width="24.9946524064171%"/> <col width="24.9946524064171%"/> <col width="25.0053475935829%"/> <col width="25.0053475935829%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="top"><span class="Bold">Indication </span> <br/> </td><td class="Rrule" valign="top"><span class="Bold">Patient Age </span> <br/> </td><td class="Rrule" valign="top"><span class="Bold">Recommended Dosage </span> <br/> </td><td class="Rrule" valign="top"><span class="Bold">Duration </span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="top">Healing of EE<br/> <br/> </td><td class="Rrule" valign="top">12 years to 17 years <br/> </td><td class="Rrule" valign="top">Esomeprazole magnesium delayed-release capsules: 20 mg or 40 mg once daily <br/> <br/> <br/> </td><td class="Rrule" valign="top">4 to 8 Weeks <br/> </td> </tr> <tr class="Last"> <td align="justify" class="Lrule Rrule" valign="top">Treatment of Symptomatic GERD<br/> <br/> </td><td class="Rrule" valign="top">12 years to 17 years <br/> </td><td class="Rrule" valign="top">Esomeprazole magnesium delayed-release capsules: 20 mg once daily <br/> <br/> <br/> <br/> </td><td class="Rrule" valign="top">4 weeks <br/> </td> </tr> </tbody> </table></div>

1 Dosages over 1 mg/kg/day have not been studied

2 Dosages over 1.33 mg/kg/day have not been studied

Esomeprazole Magnesium Delayed-Release Capsules

Administer esomeprazole magnesium delayed-release capsules orally or via a nasogastric tube, as described below.

Oral Administration

Administration via Nasogastric Tube

{ "type": "ul", "children": [ "Esomeprazole magnesium delayed-release capsules, USP 20 mg – Light yellow to brown colored enteric coated pellets filled in size “4” hard gelatin capsule, opaque dark blue cap & opaque dark blue body printed “ESOM” on cap and “20” on the body in white ink.", " Esomeprazole magnesium delayed-release capsules, USP 40 mg – Light yellow to brown colored enteric coated pellets filled in size “3” hard gelatin capsule, opaque dark blue cap & opaque dark blue body printed “ESOM” on cap and “40” on the body in white ink." ], "text": "" }

{ "type": "ul", "children": [ "Esomeprazole magnesium is contraindicated in patients with known hypersensitivity to substituted benzimidazoles or to any component of the formulation. Hypersensitivity reactions may include anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute tubulointerstitial nephritis, and urticaria [see Warnings and Precautions (5.2), Adverse Reactions (6.2)].\n", "For information about contraindications of amoxicillin and clarithromycin, indicated in combination with esomeprazole magnesium for H. pylori eradication to reduce the risk of duodenal ulcer recurrence, refer to the Contraindications section of the respective prescribing information.", "Proton pump inhibitors (PPIs), including esomeprazole magnesium, are contraindicated in patients receiving rilpivirine-containing products [see Drug Interactions (7)]." ], "text": "" }

In adults, symptomatic response to therapy with esomeprazole magnesium does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI. In older patients, also consider an endoscopy.

Acute tubulointerstitial nephritis (TIN) has been observed in patients taking PPIs and may occur at any point during PPI therapy. Patients may present with varying signs and symptoms from symptomatic hypersensitivity reactions to non-specific symptoms of decreased renal function (e.g., malaise, nausea, anorexia). In reported case series, some patients were diagnosed on biopsy and in the absence of extra-renal manifestations (e.g., fever, rash or arthralgia). Discontinue esomeprazole magnesium and evaluate patients with suspected acute TIN [see Contraindications (4)].

Published observational studies suggest that PPI therapy like esomeprazole magnesium may be associated with an increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve [see Adverse Reactions (6.2)].

Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents. For more information specific to antibacterial agents (clarithromycin and amoxicillin) indicated for use in combination with esomeprazole magnesium, refer to Warnings and Precautions section of the corresponding prescribing information.

Several published observational studies suggest that proton pump inhibitor (PPI) therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines [see Dosage and Administration (2) and Adverse Reactions (6.2)]. 

Severe cutaneous adverse reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) have been reported in association with the use of PPIs [see Adverse Reactions (6.2)].

Discontinue esomeprazole magnesium at the first signs or symptoms of severe cutaneous adverse reactions or other signs of hypersensitivity and consider further evaluation.

Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE) have been reported in patients taking PPIs, including esomeprazole. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematosus cases were CLE.

The most common form of CLE reported in patients treated with PPIs was subacute CLE (SCLE) and occurred within weeks to years after continuous drug therapy in patients ranging from infants to the elderly. Generally, histological findings were observed without organ involvement.

Systemic lupus erythematosus (SLE) is less commonly reported than CLE in patients receiving PPIs. PPI associated SLE is usually milder than non-drug induced SLE. Onset of SLE typically occurred within days to years after initiating treatment primarily in patients ranging from young adults to the elderly. The majority of patients presented with rash; however, arthralgia and cytopenia were also reported.

Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving esomeprazole magnesium, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks. Serological testing (e.g., ANA) may be positive and elevated serological test results may take longer to resolve than clinical manifestations.

Avoid concomitant use of esomeprazole magnesium with clopidogrel. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as esomeprazole, that inhibit CYP2C19 activity. Concomitant use of clopidogrel with 40 mg esomeprazole reduces the pharmacological activity of clopidogrel. When using esomeprazole magnesium consider alternative anti-platelet therapy [see Drug Interactions (7)].

Daily treatment with any acid-suppressing medications over a long period of time (e.g., longer than 3 years) may lead to malabsorption of cyanocobalamin (vitamin B-12) caused by hypo-or achlorhydria. Rare reports of cyanocobalamin deficiency occurring with acid-suppressing therapy have been reported in the literature. This diagnosis should be considered if clinical symptoms consistent with cyanocobalamin deficiency are observed. 

Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. Hypomagnesemia may lead to hypocalcemia and/or hypokalemia and may exacerbate underlying hypocalcemia in at-risk patients. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI.

For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically [see Adverse Reactions (6.2)].

Consider monitoring magnesium and calcium levels prior to initiation of esomeprazole magnesium and periodically while on treatment in patients with a preexisting risk of hypocalcemia (e.g., hypoparathyroidism). Supplement with magnesium and/or calcium, as necessary. If hypocalcemia is refractory to treatment, consider discontinuing the PPI.

Drugs which induce CYP2C19 or CYP3A4 (such as St. John’s Wort or rifampin) can substantially decrease esomeprazole concentrations [see Drug Interactions (7)]. Avoid concomitant use of esomeprazole magnesium with St. John’s Wort or rifampin. 

Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors. Healthcare providers should temporarily stop esomeprazole treatment at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g., for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary [see Clinical Pharmacology (12.2)]. 

Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration a temporary withdrawal of the PPI may be considered in some patients [see Drug Interactions (7)]. 

PPI use is associated with an increased risk of fundic gland polyps that increases with long-term use, especially beyond one year. Most PPI users who developed fundic gland polyps were asymptomatic and fundic gland polyps were identified incidentally on endoscopy. Use the shortest duration of PPI therapy appropriate to the condition being treated. 

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adults

The safety of esomeprazole magnesium delayed-release capsules was evaluated in over 15,000 patients (aged 18 to 84 years) in clinical trials worldwide including over 8,500 patients in the United States and over 6,500 patients in Europe and Canada. Over 2,900 patients were treated in long-term studies for up to 6 to 12 months.

The safety in the treatment of healing of EE in adults was assessed in four randomized comparative clinical trials, which included 1,240 patients who received esomeprazole magnesium 20 mg once daily, 2,434 patients on esomeprazole magnesium 40 mg once daily, and 3,008 patients on omeprazole 20 mg once daily. The most frequently occurring adverse reactions (at least 1%) in all three groups were headache (5.5%, 5%, and 3.8%, respectively) and diarrhea (no difference among the three groups). Nausea, flatulence, abdominal pain, constipation, and dry mouth occurred at similar rates among patients taking esomeprazole magnesium or omeprazole.

Less common adverse reactions with an incidence of less than 1% are listed below by body system:

Body as a Whole: abdomen enlarged, allergic reaction, asthenia, back pain, chest pain, substernal chest pain, facial edema, peripheral edema, hot flushes, fatigue, fever, flu-like disorder, generalized edema, leg edema, malaise, pain, rigors;

Cardiovascular: flushing, hypertension, tachycardia;

Endocrine: goiter;

Gastrointestinal: bowel irregularity, constipation aggravated, dyspepsia, dysphagia, dysplasia GI, epigastric pain, eructation, esophageal disorder, frequent stools, gastroenteritis, GI hemorrhage, GI symptoms not otherwise specified, hiccup, melena, mouth disorder, pharynx disorder, rectal disorder, serum gastrin increased, tongue disorder, tongue edema, ulcerative stomatitis, vomiting;

Hearing: earache, tinnitus;

Hematologic: anemia, anemia hypochromic, cervical lymphadenopathy, epistaxis, leukocytosis, leukopenia, thrombocytopenia;

Hepatic: bilirubinemia, hepatic function abnormal, SGOT increased, SGPT increased;

Metabolic/Nutritional: glycosuria, hyperuricemia, hyponatremia, increased alkaline phosphatase, thirst, vitamin B12 deficiency, weight increase, weight decrease;

Musculoskeletal: arthralgia, arthritis aggravated, arthropathy, cramps, fibromyalgia syndrome, hernia, polymyalgia rheumatica;

Nervous System/Psychiatric: anorexia, apathy, appetite increased, confusion, depression aggravated, dizziness, hypertonia, nervousness, hypoesthesia, impotence, insomnia, migraine, migraine aggravated, paresthesia, sleep disorder, somnolence, tremor, vertigo, visual field defect;

Reproductive: dysmenorrhea, menstrual disorder, vaginitis;

Respiratory: asthma aggravated, coughing, dyspnea, larynx edema, pharyngitis, rhinitis, sinusitis;

Skin and Appendages: acne, angioedema, dermatitis, pruritus, pruritus ani, rash, rash erythematous, rash maculo-papular, skin inflammation, sweating increased, urticaria;

Special Senses: otitis media, parosmia, taste loss, taste perversion;

Urogenital: abnormal urine, albuminuria, cystitis, dysuria, fungal infection, hematuria, micturition frequency, moniliasis, genital moniliasis, polyuria;

Visual: conjunctivitis, vision abnormal.

The following potentially clinically significant laboratory changes in clinical trials, irrespective of relationship to esomeprazole magnesium, were reported in 1% or less of patients: increased creatinine, uric acid, total bilirubin, alkaline phosphatase, ALT, AST, hemoglobin, white blood cell count, platelets, serum gastrin, potassium, sodium, thyroxine and thyroid stimulating hormone [see Clinical Pharmacology (12.2)]. Decreases were seen in hemoglobin, white blood cell count, platelets, potassium, sodium, and thyroxine.

Endoscopic findings that were reported as adverse reactions include: duodenitis, esophagitis, esophageal stricture, esophageal ulceration, esophageal varices, gastric ulcer, gastritis, hernia, benign polyps or nodules, Barrett’s esophagus, and mucosal discoloration.

The incidence of adverse reactions during 6-month trials for the maintenance of healing of EE with esomeprazole magnesium 20 mg once daily was similar to placebo. There were no differences in types of adverse reactions seen during maintenance treatment up to 12 months compared to short-term treatment.

Two placebo-controlled studies were conducted in 710 adult patients for the treatment of symptomatic GERD. The most common adverse reactions that were reported were: diarrhea (4%), headache (4%), and abdominal pain (4%).

Combination Treatment with esomeprazole magnesium, Amoxicillin and Clarithromycin

In clinical trials of H. pylori eradication of to reduce duodenal ulcer recurrence, no additional adverse reactions specific to the combination of esomeprazole magnesium delayed-release capsules, amoxicillin and clarithromycin were observed and were similar to those observed with esomeprazole magnesium, amoxicillin, or clarithromycin alone. The most frequently reported adverse reactions for patients who received esomeprazole magnesium, amoxicillin and clarithromycin for 10 days were diarrhea (9%), taste perversion (4%), and abdominal pain (4%). No adverse reactions were observed at higher rates with esomeprazole magnesium, amoxicillin and clarithromycin than were observed with esomeprazole magnesium alone.

In clinical trials using of esomeprazole magnesium, amoxicillin and clarithromycin, no additional increased laboratory abnormalities particular to these drug combinations were observed.

For more information on adverse reactions and laboratory changes with amoxicillin or clarithromycin, refer to Adverse Reactions section of the respective prescribing information.

Pediatrics

1 Year to 17 Years of Age

The safety of esomeprazole magnesium delayed-release capsules and NEXIUM for delayed-release oral suspension was evaluated in 316 pediatric and adolescent patients aged 1 year to 17 years in four clinical trials for the treatment of symptomatic GERD [see Clinical Studies (14.3)]. In 109 pediatric patients aged 1 year to 11 years, the most frequently reported (at least 1%) treatment-related adverse reactions in these patients were diarrhea (3%), headache (2%) and somnolence (2%). In 149 pediatric patients aged 12 years to 17 years the most frequently reported adverse reactions (at least 2%) were headache (8%), abdominal pain (3%), diarrhea (2%), and nausea (2%). 

The following adverse reactions have been identified during post-approval use of esomeprazole. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reports are listed below by body system:

Blood and Lymphatic: agranulocytosis, pancytopenia;

Eye: blurred vision;

Gastrointestinal: pancreatitis; stomatitis; microscopic colitis; fundic gland polyps;

Hepatobiliary: hepatic failure, hepatitis with or without jaundice;

Immune System: anaphylactic reaction/shock; systemic lupus erythematosus;

Infections and Infestations: GI candidiasis; Clostridium difficile-associated diarrhea;

Metabolism and nutritional disorders: hypomagnesemia (may lead to hypocalcemia and/or hypokalemia) [see Warnings and Precautions (5.9)];

Musculoskeletal and Connective Tissue: muscular weakness, myalgia, bone fracture;

Nervous System: hepatic encephalopathy, taste disturbance;

Psychiatric: aggression, agitation, depression, hallucination;

Renal and Urinary: interstitial nephritis;

Reproductive System and Breast: gynecomastia, erectile dysfunction;

Respiratory, Thoracic, and Mediastinal: bronchospasm;

Skin and Subcutaneous Tissue: alopecia, erythema multiforme, hyperhidrosis, photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis (some fatal), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP), cutaneous lupus erythematosus.

Adverse reactions associated with omeprazole may also be expected to occur with esomeprazole. See the full prescribing information for omeprazole for complete safety information.

Tables 3 and 4 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them.

{ "type": "p", "children": [], "text": "Tables 3 and 4 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them. " }

Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs.

{ "type": "p", "children": [], "text": "Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs. " }

Table 3: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics

{ "type": "p", "children": [], "text": "\nTable 3: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics\n" }

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="0"> <colgroup> <col width="26.851950828434%"/> <col width="73.148049171566%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Antiretrovirals </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact:</span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top">The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known. <br/> <ul class="Disc"> <li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class="Italics">[see <span class="Underline">Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)</span>]. </span> </li> <li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class="Italics">[see <span class="Underline">Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)</span>].</span> </li> <li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole. </li> </ul> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention:</span> <br/> </td><td align="justify" class="Rrule" valign="top"><span class="Underline">Rilpivirine-containing products:</span> Concomitant use with esomeprazole magnesium is contraindicated <span class="Italics">[see <span class="Underline">Contraindications (<a href="#Section_4">4</a>)</span>]</span>. <br/> <span class="Underline">Atazanavir</span>: See prescribing information for atazanavir for dosing information. <br/> <span class="Underline">Nelfinavir</span>: Avoid concomitant use with esomeprazole magnesium. See prescribing information for nelfinavir. <br/> <span class="Underline">Saquinavir:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities. <br/> <span class="Underline">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Warfarin </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="top"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range. <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Methotrexate </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact: </span> <br/> <br/> </td><td align="justify" class="Rrule" valign="top">Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class="Italics">[see Warnings and Precautions (<a href="#Section_5.12">5.12</a>)]. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">A temporary withdrawal of esomeprazole magnesium may be considered in some patients receiving high-dose methotrexate. <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol) </span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Clopidogrel </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)]. </span>There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel<span class="Italics">. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Avoid concomitant use with esomeprazole magnesium Consider use of alternative anti-platelet therapy <span class="Italics">[see Warnings and Precautions (<a href="#Section_5.7">5.7</a>)]. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Citalopram </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Increased exposure of citalopram leading to an increased risk of QT prolongation <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)]. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram. <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Cilostazol </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)]. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol. <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Digoxin </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Potential for increased exposure of digoxin <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)]. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin. <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Combination Therapy with Clarithromycin and Amoxicillin </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Concomitant administration of clarithromycin with other drugs can lead to serious adverse reactions, including potentially fatal arrhythmias, and are contraindicated. Amoxicillin also has drug interactions. <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">See <span class="Italics">Contraindications, Warnings </span>and <span class="Italics">Precautions </span>in prescribing information for clarithromycin. See <span class="Italics">Drug Interactions </span>in prescribing information for amoxicillin. <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole) </span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="middle">Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole magnesium and MMF. Use esomeprazole magnesium with caution in transplant patients receiving MMF <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)]</span>. See the prescribing information for other drugs dependent on gastric pH for absorption. <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Tacrolimus </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class="Italics">. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus. <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Interactions with Investigations of Neuroendocrine Tumors </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class="Italics">[see Warnings and Precautions (<a href="#Section_5.11">5.11</a>), Clinical Pharmacology (<a href="#Section_12.2">12.2</a>)]. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Discontinue esomeprazole magnesium at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary. <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Interaction with Secretin Stimulation Test </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma. <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">Discontinue esomeprazole magnesium 4 weeks prior to testing <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.2">12.2</a>)] </span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">False Positive Urine Tests for THC </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td align="justify" class="Rrule" valign="top">There have been reports of false positive urine screening test for tetrahydrocannabinol (THC) in patients receiving PPIs. <br/> </td> </tr> <tr class="Last"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td align="justify" class="Rrule" valign="top">An alternative confirmatory method should be considered to verify positive results. <br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\">\n<colgroup>\n<col width=\"26.851950828434%\"/>\n<col width=\"73.148049171566%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Antiretrovirals </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact:</span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known. <br/>\n<ul class=\"Disc\">\n<li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class=\"Italics\">[see <span class=\"Underline\">Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)</span>]. </span>\n</li>\n<li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class=\"Italics\">[see <span class=\"Underline\">Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)</span>].</span>\n</li>\n<li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole. </li>\n</ul>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\"><span class=\"Underline\">Rilpivirine-containing products:</span> Concomitant use with esomeprazole magnesium is contraindicated <span class=\"Italics\">[see <span class=\"Underline\">Contraindications (<a href=\"#Section_4\">4</a>)</span>]</span>. <br/>\n<span class=\"Underline\">Atazanavir</span>: See prescribing information for atazanavir for dosing information. <br/>\n<span class=\"Underline\">Nelfinavir</span>: Avoid concomitant use with esomeprazole magnesium. See prescribing information for nelfinavir. <br/>\n<span class=\"Underline\">Saquinavir:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities. <br/>\n<span class=\"Underline\">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Warfarin </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Methotrexate </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact: </span>\n<br/> <br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class=\"Italics\">[see Warnings and Precautions (<a href=\"#Section_5.12\">5.12</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">A temporary withdrawal of esomeprazole magnesium may be considered in some patients receiving high-dose methotrexate. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol) </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Clopidogrel </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)]. </span>There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel<span class=\"Italics\">. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Avoid concomitant use with esomeprazole magnesium Consider use of alternative anti-platelet therapy <span class=\"Italics\">[see Warnings and Precautions (<a href=\"#Section_5.7\">5.7</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Citalopram </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Increased exposure of citalopram leading to an increased risk of QT prolongation <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Cilostazol </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Digoxin </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Potential for increased exposure of digoxin <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Combination Therapy with Clarithromycin and Amoxicillin </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Concomitant administration of clarithromycin with other drugs can lead to serious adverse reactions, including potentially fatal arrhythmias, and are contraindicated. Amoxicillin also has drug interactions. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">See <span class=\"Italics\">Contraindications, Warnings </span>and <span class=\"Italics\">Precautions </span>in prescribing information for clarithromycin. See <span class=\"Italics\">Drug Interactions </span>in prescribing information for amoxicillin. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole) </span>\n<br/> <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole magnesium and MMF. Use esomeprazole magnesium with caution in transplant patients receiving MMF <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)]</span>. See the prescribing information for other drugs dependent on gastric pH for absorption. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Tacrolimus </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class=\"Italics\">. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Interactions with Investigations of Neuroendocrine Tumors </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class=\"Italics\">[see Warnings and Precautions (<a href=\"#Section_5.11\">5.11</a>), Clinical Pharmacology (<a href=\"#Section_12.2\">12.2</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Discontinue esomeprazole magnesium at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Interaction with Secretin Stimulation Test </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma. <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Discontinue esomeprazole magnesium 4 weeks prior to testing <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.2\">12.2</a>)] </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">False Positive Urine Tests for THC </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">There have been reports of false positive urine screening test for tetrahydrocannabinol (THC) in patients receiving PPIs. <br/>\n</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">An alternative confirmatory method should be considered to verify positive results. <br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

Table 4: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs

{ "type": "p", "children": [], "text": "\nTable 4: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs\n" }

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="0"> <colgroup> <col width="26.8840192410476%"/> <col width="73.1159807589524%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">CYP2C19 or CYP3A4 Inducers </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td class="Rrule" valign="top">Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)]. </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td class="Rrule" valign="top">St. John’s Wort, rifampin: Avoid concomitant use with <span class="Italics">[see Warnings and Precautions (<a href="#Section_5.10">5.10</a>)]. </span>Ritonavir-containing products: see prescribing information for specific drugs <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Voriconazole </span> <br/> </td> </tr> <tr class="Botrule"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact: </span> <br/> </td><td class="Rrule" valign="top">Increased exposure of esomeprazole <span class="Italics">[see Clinical Pharmacology (<a href="#Section_12.3">12.3</a>)]. </span> <br/> </td> </tr> <tr class="Last"> <td align="right" class="Lrule Rrule" valign="middle"><span class="Italics">Intervention: </span> <br/> </td><td class="Rrule" valign="top">Dose adjustment of esomeprazole magnesium is not normally required. However, in patients with Zollinger-Ellison syndrome, who may require higher doses, dosage adjustment may be considered. See prescribing information for voriconazole. <br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\">\n<colgroup>\n<col width=\"26.8840192410476%\"/>\n<col width=\"73.1159807589524%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">CYP2C19 or CYP3A4 Inducers </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td class=\"Rrule\" valign=\"top\">Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td class=\"Rrule\" valign=\"top\">St. John’s Wort, rifampin: Avoid concomitant use with <span class=\"Italics\">[see Warnings and Precautions (<a href=\"#Section_5.10\">5.10</a>)]. </span>Ritonavir-containing products: see prescribing information for specific drugs <br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Voriconazole </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact: </span>\n<br/>\n</td><td class=\"Rrule\" valign=\"top\">Increased exposure of esomeprazole <span class=\"Italics\">[see Clinical Pharmacology (<a href=\"#Section_12.3\">12.3</a>)]. </span>\n<br/>\n</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"right\" class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention: </span>\n<br/>\n</td><td class=\"Rrule\" valign=\"top\">Dose adjustment of esomeprazole magnesium is not normally required. However, in patients with Zollinger-Ellison syndrome, who may require higher doses, dosage adjustment may be considered. See prescribing information for voriconazole. <br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

Risk Summary

There are no adequate and well-controlled studies with esomeprazole in pregnant women. Esomeprazole is the S-isomer of omeprazole. Available epidemiologic data fail to demonstrate an increased risk of major congenital malformations or other adverse pregnancy outcomes with first trimester omeprazole use (see Data). Reproduction studies in rats and rabbits resulted in dose-dependent embryo-lethality at omeprazole doses that were approximately 3.4 to 34 times an oral human dose of 40 mg (based on a body surface area for a 60 kg person).

Teratogenicity was not observed in animal reproduction studies with administration of oral esomeprazole magnesium in rats and rabbits with doses about 68 times and 42 times, respectively, an oral human dose of 40 mg (based on a body surface area basis for a 60 kg person). Changes in bone morphology were observed in offspring of rats dosed through most of pregnancy and lactation at doses equal to or greater than approximately 34 times an oral human dose of 40 mg. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age (see Data).

The estimated background risks of major birth defects and miscarriage for the indicated population are unknown. All pregnancies have a background risk of birth defect, loss or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

Data

Human Data

Esomeprazole is the S-isomer of omeprazole. Four epidemiological studies compared the frequency of congenital abnormalities among infants born to women who used omeprazole during pregnancy with the frequency of abnormalities among infants of women exposed to H2-receptor antagonists or other controls.

A population-based retrospective cohort epidemiological study from the Swedish Medical Birth Registry, covering approximately 99% of pregnancies, from 1995 to 1999, reported on 955 infants (824 exposed during the first trimester with 39 of these exposed beyond first trimester, and 131 exposed after the first trimester) whose mothers used omeprazole during pregnancy. The number of infants exposed in utero to omeprazole that had any malformation, low birth weight, low Apgar score, or hospitalization was similar to the number observed in this population. The number of infants born with ventricular septal defects and the number of stillborn infants was slightly higher in the omeprazole-exposed infants than the expected number in this population.

A population-based retrospective cohort study covering all live births in Denmark from 1996 to 2009, reported on 1,800 live births whose mothers used omeprazole during the first trimester of pregnancy and 837,317 live births whose mothers did not use any proton pump inhibitor. The overall rate of birth defects in infants born to mothers with first trimester exposure to omeprazole was 2.9% and 2.6% in infants born to mothers not exposed to any proton pump inhibitor during the first trimester.

A retrospective cohort study reported on 689 pregnant women exposed to either H2-blockers or omeprazole in the first trimester (134 exposed to omeprazole) and 1,572 pregnant women unexposed to either during the first trimester. The overall malformation rate in offspring born to mothers with first trimester exposure to omeprazole, an H2-blocker, or were unexposed was 3.6%, 5.5%, and 4.1% respectively.

A small prospective observational cohort study followed 113 women exposed to omeprazole during pregnancy (89% with first trimester exposures). The reported rate of major congenital malformations was 4% in the omeprazole group, 2% in controls exposed to non-teratogens, and 2.8% in disease paired controls. Rates of spontaneous and elective abortions, preterm deliveries, gestational age at delivery, and mean birth weight were similar among the groups.

Several studies have reported no apparent adverse short-term effects on the infant when single dose oral or intravenous omeprazole was administered to over 200 pregnant women as premedication for cesarean section under general anesthesia.

Animal Data

Omeprazole

Reproductive studies conducted with omeprazole in rats at oral doses up to 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at doses up to 69.1 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) during organogenesis did not disclose any evidence for a teratogenic potential of omeprazole. In rabbits, omeprazole in a dose range of 6.9 to 69.1 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis produced dose-related increases in embryo-lethality, fetal resorptions, and pregnancy disruptions. In rats, dose-related embryo/fetal toxicity and postnatal developmental toxicity were observed in offspring resulting from parents treated with omeprazole at 13.8 to 138.0 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis), administered prior to mating through the lactation period.

Esomeprazole

No effects on embryo-fetal development were observed in reproduction studies with esomeprazole magnesium in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) or in rabbits at oral doses up to 86 mg/kg/day (about 41 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis.

A pre-and postnatal developmental toxicity study in rats with additional endpoints to evaluate bone development was performed with esomeprazole magnesium at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). Neonatal/early postnatal (birth to weaning) survival was decreased at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). Body weight and body weight gain were reduced and neurobehavioral or general developmental delays in the immediate post-weaning timeframe were evident at doses equal to or greater than 69 mg/kg/day (about 17 times an oral human dose of 40 mg on a body surface area basis). In addition, decreased femur length, width and thickness of cortical bone, decreased thickness of the tibial growth plate and minimal to mild bone marrow hypocellularity were noted at doses equal to or greater than 14 mg/kg/day (about 3.4 times an oral human dose of 40 mg on a body surface area basis). Physeal dysplasia in the femur was observed in offspring of rats treated with oral doses of esomeprazole magnesium at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis).

Effects on maternal bone were observed in pregnant and lactating rats in a pre-and postnatal toxicity study when esomeprazole magnesium was administered at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). When rats were dosed from gestational day 7 through weaning on postnatal day 21, a statistically significant decrease in maternal femur weight of up to 14% (as compared to placebo treatment) was observed at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis).

A pre-and postnatal development study in rats with esomeprazole strontium (using equimolar doses compared to esomeprazole magnesium study) produced similar results in dams and pups as described above.

A follow up developmental toxicity study in rats with further time points to evaluate pup bone development from postnatal day 2 to adulthood was performed with esomeprazole magnesium at oral doses of 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) where esomeprazole administration was from either gestational day 7 or gestational day 16 until parturition. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age.

Risk Summary

Esomeprazole is the S-isomer of omeprazole and limited data suggest that omeprazole may be present in human milk. There are no clinical data on the effects of esomeprazole on the breastfed infant or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for esomeprazole magnesium and any potential adverse effects on the breastfed infant from esomeprazole magnesium or from the underlying maternal condition. 

Healing of EE

Pediatric Patients 1 Year to 17 Years of Age

The safety and effectiveness of esomeprazole magnesium delayed-release capsules and NEXIUM for delayed-release oral suspension

have been established in pediatric patients 12 years to 17 years for short-term treatment (4 to 8 weeks) for healing of EE.

Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety and pharmacokinetic data in pediatric patients 1 year to 17 years of age. The safety profile in pediatric patients 1 year to 17 years of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.4)].

Symptomatic GERD

Pediatric Patients 1 Year to 17 Years of Age

The safety and effectiveness of esomeprazole magnesium delayed-release capsules and NEXIUM for delayed-release oral suspension have been established in pediatric patients 12 years to 17 years of age for the short-term treatment (4 weeks) of heartburn and other symptoms associated with GERD. Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety and pharmacokinetic data in pediatric patients 1 year to 17 years of age. The safety profile in pediatric patients 1 year to 17 years of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.4)].

The safety and effectiveness of esomeprazole magnesium delayed-release capsules for the treatment of symptomatic GERD in pediatric patients less than 1 year of age have not been established.

Other Conditions

The safety and effectiveness of esomeprazole magnesium for the risk reduction of NSAID-associated gastric ulcer, H. pylori eradication to reduce the risk of duodenal ulcer recurrence and treatment of pathological hypersecretory conditions have not been established in pediatric patients.

Juvenile Animal Toxicity Studies

In a juvenile rat toxicity study, esomeprazole was administered with both magnesium and strontium salts at oral doses about 34 to 68 times a daily human dose of 40 mg based on body surface area. Increases in death were seen at the high dose, and at all doses of esomeprazole, there were decreases in body weight, body weight gain, femur weight and femur length, and decreases in overall growth [see Nonclinical Toxicology (13.2)].

Of the total number of patients who received esomeprazole magnesium in clinical trials, 1459 were 65 to 74 years of age and 354 patients were 75 years of age and older.

No overall differences in safety and efficacy were observed between the elderly and younger individuals, and other reported clinical experience has not identified differences in responses between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. 

In patients with severe hepatic impairment (Child-Pugh Class C) exposure to esomeprazole substantially increased compared to healthy subjects. Dosage modification of esomeprazole magnesium is recommended for patients with severe hepatic impairment for the healing of EE, risk reduction of NSAID-associated gastric ulcer, H. pylori eradication to reduce the risk of duodenal ulcer recurrence, and pathological hypersecretory conditions including Zollinger-Ellison Syndrome [see Dosage and Administration (2.1), Clinical Pharmacology (12.3)].

In patients with mild to moderate liver impairment (Child-Pugh Classes A and B), no dosage adjustment is necessary. 

Manifestations in patients exposed to omeprazole, the racemic mixture, at doses up to 2,400 mg (120 times the usual recommended clinical dose) include confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive.

{ "type": "p", "children": [], "text": "Manifestations in patients exposed to omeprazole, the racemic mixture, at doses up to 2,400 mg (120 times the usual recommended clinical dose) include confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive. " }

If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage. 

{ "type": "p", "children": [], "text": "If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage. " }

The active ingredient in the proton pump inhibitor esomeprazole magnesium delayed-release capsules, USP for oral administration is bis (5-methoxy-2-[(S)-[(4-methoxy-3, 5-dimethyl-2-pyridinyl) methyl]sulfinyl]-1H-benzimidazole-1-yl) magnesium trihydrate. Esomeprazole is the S- isomer of omeprazole, which is a mixture of the S- and R- isomers. (Initial U.S. approval of esomeprazole magnesium: 2001). Its molecular formula is C34H36MgN6O6S2•3H2O with molecular weight of 767.2 as a trihydrate and 713.1 on an anhydrous basis. The structural formula is:

{ "type": "p", "children": [], "text": "The active ingredient in the proton pump inhibitor esomeprazole magnesium delayed-release capsules, USP for oral administration is bis (5-methoxy-2-[(S)-[(4-methoxy-3, 5-dimethyl-2-pyridinyl) methyl]sulfinyl]-1H-benzimidazole-1-yl) magnesium trihydrate. Esomeprazole is the S- isomer of omeprazole, which is a mixture of the S- and R- isomers. (Initial U.S. approval of esomeprazole magnesium: 2001). Its molecular formula is C34H36MgN6O6S2•3H2O with molecular weight of 767.2 as a trihydrate and 713.1 on an anhydrous basis. The structural formula is:" }

The magnesium salt is a white to slightly colored crystalline powder. It contains 3 moles of water of solvation and is slightly soluble in water. The stability of esomeprazole magnesium is a function of pH; it rapidly degrades in acidic media, but it has acceptable stability under alkaline conditions. At pH 6.8 (buffer), the half-life of the magnesium salt is about 19 hours at 25°C and about 8 hours at 37°C.

{ "type": "p", "children": [], "text": "The magnesium salt is a white to slightly colored crystalline powder. It contains 3 moles of water of solvation and is slightly soluble in water. The stability of esomeprazole magnesium is a function of pH; it rapidly degrades in acidic media, but it has acceptable stability under alkaline conditions. At pH 6.8 (buffer), the half-life of the magnesium salt is about 19 hours at 25°C and about 8 hours at 37°C. " }

Esomeprazole magnesium is supplied as Esomeprazole magnesium delayed-release capsules, USP. Each delayed-release capsule contains 20 mg, or 40 mg of esomeprazole (present as 22.3 mg, or 44.5 mg esomeprazole magnesium trihydrate) in the form of enteric-coated pellets with the following inactive ingredients: Colloidal silicon dioxide, hypromellose, magnesium stearate, meglumine, methacrylic acid and ethyl acrylate copolymer dispersion, mono & diglycerides, poloxamer, sugar spheres, talc and triethyl citrate.

{ "type": "p", "children": [], "text": "Esomeprazole magnesium is supplied as Esomeprazole magnesium delayed-release capsules, USP. Each delayed-release capsule contains 20 mg, or 40 mg of esomeprazole (present as 22.3 mg, or 44.5 mg esomeprazole magnesium trihydrate) in the form of enteric-coated pellets with the following inactive ingredients: Colloidal silicon dioxide, hypromellose, magnesium stearate, meglumine, methacrylic acid and ethyl acrylate copolymer dispersion, mono & diglycerides, poloxamer, sugar spheres, talc and triethyl citrate. " }

The capsule shells and Imprinting Ink have the following inactive ingredients: Capsule shell: gelatin, FD & C Blue 1, FD & C Red 40, titanium dioxide, sodium lauryl sulphate and Imprinting Ink: potassium hydroxide, shellac, and titanium dioxide.

{ "type": "p", "children": [], "text": "The capsule shells and Imprinting Ink have the following inactive ingredients: Capsule shell: gelatin, FD & C Blue 1, FD & C Red 40, titanium dioxide, sodium lauryl sulphate and Imprinting Ink: potassium hydroxide, shellac, and titanium dioxide." }

Meets USP Dissolution Test 2.

{ "type": "p", "children": [], "text": "Meets USP Dissolution Test 2." }

Esomeprazole belongs to a class of antisecretory compounds, the substituted benzimidazoles, that suppress gastric acid secretion by specific inhibition of the H+/K+ ATPase enzyme system at the secretory surface of the gastric parietal cell. Esomeprazole is protonated and converted in the acidic compartment of the parietal cell forming the active inhibitor, the achiral sulphenamide. Because this enzyme system is regarded as the acid (proton) pump within the gastric mucosa, esomeprazole has been characterized as a gastric acid-pump inhibitor, in that it blocks the final step of acid production. This effect is dose-related and leads to inhibition of both basal and stimulated acid secretion irrespective of the stimulus. 

Antisecretory Activity

Adults

The effect of esomeprazole on intragastric pH was determined in adult patients with symptomatic GERD in two separate studies. In the first study of 36 patients, esomeprazole magnesium 40 mg and 20 mg delayed-release capsules were administered once daily over 5 days as shown in Table 5:

Table 5: Effect of Esomeprazole on Intragastric pH on Day 5 (N=36) Following Once Daily Dosing of Esomeprazole Magnesium Delayed-Release Capsules in Adult Patients with Symptomatic GERD

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0"> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle"> Parameter</td><td class="Rrule" colspan="2" valign="middle"> Esomeprazole Magnesium Delayed-Release Capsules</td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"> </td><td align="center" class="Rrule" valign="middle"> <br/> 40 mg once daily</td><td align="center" class="Rrule" valign="middle"> <br/>20 mg once daily </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/>% Time Gastric pH &gt;4<span class="Italics"><span class="Sup">1</span></span>(Hours)  </td><td align="center" class="Rrule" valign="middle"> <br/>70%2 (16.8 h) </td><td align="center" class="Rrule" valign="middle"> <br/> 53% (12.7 h)</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" valign="middle"> <br/> Coefficient of variation </td><td align="center" class="Rrule" valign="middle"> <br/> 26%</td><td align="center" class="Rrule" valign="middle"> <br/> 37%</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" valign="middle"> <br/>Median 24 Hour pH </td><td align="center" class="Rrule" valign="middle"> <br/> 4.9<span class="Sup">2</span></td><td align="center" class="Rrule" valign="middle"> <br/> 4.1</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule" valign="middle"> <br/> Coefficient of variation 16% 27%</td><td align="center" class="Rrule" valign="middle"> <br/> 16%</td><td align="center" class="Rrule" valign="middle"> <br/> 27%</td> </tr> </tbody> </table></div>

In a second study, the effect on intragastric pH of esomeprazole magnesium 40 mg delayed-release capsules administered once daily over a five-day period was similar to the first study, (% time with pH > 4 was 68% or 16.3 hours).

Serum Gastrin Effects

The effect of esomeprazole on serum gastrin concentrations was evaluated in approximately 2,700 patients in clinical trials of oral esomeprazole for up to 8 weeks and in over 1,300 patients for up to 12 months. The mean fasting gastrin level increased in a dose-related manner. The increase in serum gastrin concentrations reached a plateau within two to three months of therapy and returned to baseline levels within four weeks after discontinuation of therapy.

Increased gastrin causes enterochromaffin-like cell hyperplasia and increased serum Chromogranin A (CgA) levels. The increased CgA levels may cause false positive results in diagnostic investigations for neuroendocrine tumors [see Warnings and Precautions (5.11)]

Enterochromaffin-like (ECL) Cell Effects

Human gastric biopsy specimens have been obtained from more than 3,000 patients (both pediatrics and adults) treated with omeprazole in long-term clinical trials. The incidence of ECL cell hyperplasia in these studies increased with time; however, no case of ECL cell carcinoids, dysplasia, or neoplasia has been found in these patients [see Nonclinical Toxicology (13.1)]

In over 1,000 patients treated with oral esomeprazole (10 mg, 20 mg or 40 mg/day) for up to 12 months, the prevalence of ECL cell hyperplasia increased with time and dose. No patient developed ECL cell carcinoids, dysplasia, or neoplasia in the gastric mucosa.

Endocrine Effects

Esomeprazole had no effect on thyroid function in adults when given esomeprazole magnesium 20 mg or 40 mg delayed-release capsules once daily for 4 weeks. Other effects of esomeprazole on the endocrine system were assessed in studies of omeprazole. Oral doses of omeprazole 30 mg or 40 mg once daily for 2 to 4 weeks had no effect on carbohydrate metabolism, circulating levels of parathyroid hormone, cortisol, estradiol, testosterone, prolactin, cholecystokinin, or secretin. 

Absorption

Esomeprazole magnesium delayed-release capsules and NEXIUM for delayed-release oral suspension showed similar bioavailability after a single dose (40 mg) administration in 94 healthy male and female subjects under fasting conditions. After oral administration, peak plasma levels (Cmax) of esomeprazole occur at approximately 1.5 hours (Tmax). The Cmax increases proportionally when the dose is increased, and there is a three-fold increase in the area under the plasma concentration-time curve (AUC) from 20 to 40 mg. At repeated once-daily dosing with 40 mg, the systemic bioavailability is approximately 90% compared to 64% after a single dose of 40 mg. The mean exposure (AUC) to esomeprazole increases from 4.32 micromol*hr/L on Day 1 to 11.2 micromol*hr/L on Day 5 after 40 mg once daily dosing.

The AUC after administration of a single 40 mg dose of esomeprazole magnesium delayed-release capsules is decreased by 43% to 53% after food intake compared to fasting conditions [see Dosage and Administration (2.3)]. The pharmacokinetics of esomeprazole in adult patients with symptomatic GERD following repeated once daily administration of 20 mg and 40 mg esomeprazole magnesium delayed-release capsules over a period of five days are shown in Table 6:

Table 6: Geometric Mean (95% CI) Pharmacokinetic Parameters of Esomeprazole on Day 5 Following Once Daily Dosing of Esomeprazole Magnesium Delayed-Release Capsules in Adult Patients with Symptomatic GERD

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="621.775"> <colgroup> <col width="33.3262032085562%"/> <col width="33.3368983957219%"/> <col width="33.3368983957219%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="justify" class="Lrule Rrule" valign="top"> <br/> </td><td align="center" class="Rrule" colspan="2" valign="top"><span class="Bold">Esomeprazole magnesium delayed-release capsules</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Bold">Parameter <span class="Italics"><span class="Sup">1</span></span>(CV) </span> <br/> </td><td class="Rrule" valign="top"><span class="Bold">40 mg once daily (n=36) </span> <br/> </td><td class="Rrule" valign="top"><span class="Bold">20 mg once daily (n=36) </span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">AUC (micromol·h/L) <br/> </td><td class="Rrule" valign="top">12.6 (42%) <br/> </td><td class="Rrule" valign="top">4.2 (59%) <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">C<span class="Sub">max</span> (micromol/L) <br/> </td><td class="Rrule" valign="middle">4.7 (37%) <br/> </td><td class="Rrule" valign="middle">2.1 (45%) <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">T<span class="Sub">max</span> (hours) <br/> </td><td class="Rrule" valign="top">1.6 <br/> </td><td class="Rrule" valign="top">1.6 <br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top">t<span class="Sub">1/2</span> (hours) <br/> </td><td class="Rrule" valign="middle">1.5 <br/> </td><td class="Rrule" valign="middle">1.2 <br/> </td> </tr> </tbody> </table></div>

1. Values represent the geometric mean, except the Tmax, which is the arithmetic mean; CV = Coefficient of variation

Esomeprazole is a time-dependent inhibitor of CYP2C19, resulting in autoinhibition and nonlinear pharmacokinetics. The systemic exposure increases in a more than dose proportional manner after multiple oral doses of esomeprazole.

Compared to the first dose, the systemic exposure (Cmax and AUC0-24h) at steady state following once a day dosing increased by 43% and 90%, respectively, compared to after the first dose for the 20 mg dose and increased by 95% and 159%, respectively, for the 40 mg dose.

Distribution

Esomeprazole is 97% bound to plasma proteins. Plasma protein binding is constant over the concentration range of 2 to 20 micromol/L. The apparent volume of distribution at steady state in healthy subjects is approximately 16 L.

Elimination

Metabolism

Esomeprazole is extensively metabolized in the liver by the cytochrome P450 (CYP) enzyme system. The metabolites of esomeprazole lack antisecretory activity. The major part of esomeprazole’s metabolism is dependent upon the CYP2C19 isoenzyme, which forms the hydroxy and desmethyl metabolites. The remaining amount is dependent on CYP3A4 which forms the sulphone metabolite.

Excretion

The plasma elimination half-life of esomeprazole is approximately 1 to 1.5 hours. Less than 1% of parent drug is excreted in the urine. Approximately 80% of an oral dose of esomeprazole is excreted as inactive metabolites in the urine, and the remainder is found as inactive metabolites in the feces.

Combination Therapy with Amoxicillin and Clarithromycin

Esomeprazole magnesium delayed-release capsules 40 mg once daily was given in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily for 7 days to 17 healthy male and female subjects. The mean steady state AUC and Cmax of esomeprazole increased by 70% and 18%, respectively during combination therapy compared to treatment with esomeprazole magnesium alone. The observed increase in esomeprazole exposure during co-administration with amoxicillin and clarithromycin is not expected to be clinically relevant.

The pharmacokinetic parameters for amoxicillin and clarithromycin were similar during combination therapy and administration of each drug alone. However, the mean AUC and Cmax for 14-hydroxyclarithromycin increased by 19% and 22%, respectively, during combination therapy compared to treatment with clarithromycin alone. This increase in exposure to 14-hydroxyclarithromycin is not considered to be clinically relevant.

Specific Populations

Geriatric Patients

The AUC and Cmax values of esomeprazole were slightly higher (25% and 18%, respectively) in the elderly as compared to younger subjects at steady state. This increase in exposure is not considered clinically relevant.

Pediatric Patients

12 Years to 17 Years of Age

The pharmacokinetics of esomeprazole magnesium were studied in 28 adolescent patients with GERD aged 12 to 17 years inclusive, in a single center study. Patients were randomized to receive esomeprazole magnesium 20 mg or 40 mg once daily for 8 days. Mean Cmax and AUC values of esomeprazole were not affected by body weight or age; and more than dose-proportional increases in mean Cmax and AUC values were observed between the two dose groups in the study. Overall, esomeprazole magnesium pharmacokinetics in adolescent patients aged 12 to 17 years were similar to those observed in adult patients with symptomatic GERD. See Table 9.

Table 9: Comparison of Esomeprazole Pharmacokinetic Parameters Following Once Daily Dosing of Esomeprazole Magnesium Delayed-Release Capsules in Pediatric Patients 12 Years to 17 Years with GERD and Adults with Symptomatic GERD1

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="621.775"> <colgroup> <col width="20%"/> <col width="20%"/> <col width="20%"/> <col width="20%"/> <col width="20%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="justify" class="Lrule Rrule" valign="top"><span class="Bold">Parameter </span> <br/> </td><td align="center" class="Rrule" colspan="4" valign="top"><span class="Bold">Esomeprazole Magnesium Delayed-Release Capsules</span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"> <br/> </td><td align="justify" class="Rrule" colspan="2" valign="top"><span class="Bold">12 Years to 17 Years (N=28) </span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="top"><span class="Bold">Adults (N=36)</span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top"> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold">20 mg once daily for 8 days</span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold">40 mg once daily for 8 days</span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold">20 mg once daily for 5 days</span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold">40 mg once daily for 5 days</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">AUC (micromol·h/L) <br/> </td><td align="center" class="Rrule" valign="middle">3.65 <br/> </td><td align="center" class="Rrule" valign="middle">13.86 <br/> </td><td align="center" class="Rrule" valign="middle">4.2 <br/> </td><td align="center" class="Rrule" valign="middle">12.6 <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">C<span class="Sub">max</span> (micromol/L) <br/> </td><td align="center" class="Rrule" valign="top">1.45 <br/> </td><td align="center" class="Rrule" valign="top">5.13 <br/> </td><td align="center" class="Rrule" valign="top">2.1 <br/> </td><td align="center" class="Rrule" valign="top">4.7 <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">t<span class="Sub">max</span> (h) <br/> </td><td align="center" class="Rrule" valign="middle">2.00 <br/> </td><td align="center" class="Rrule" valign="middle">1.75 <br/> </td><td align="center" class="Rrule" valign="middle">1.6 <br/> </td><td align="center" class="Rrule" valign="middle">1.6 <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">t<span class="Sub">½</span>λz (h) <br/> </td><td align="center" class="Rrule" valign="top">0.82 <br/> </td><td align="center" class="Rrule" valign="top">1.22 <br/> </td><td align="center" class="Rrule" valign="top">1.2 <br/> </td><td align="center" class="Rrule" valign="top">1.5 <br/> </td> </tr> <tr class="Last"> <td align="justify" class="Lrule Rrule" colspan="5" valign="top">Data presented are geometric means for AUC, C<span class="Sub">max</span> and t<span class="Sub">½λz</span>, and median value for t<span class="Sub">max</span>. <br/> </td> </tr> </tbody> </table></div>

1. Data obtained from two independent studies

Male and Female Patients

The AUC and Cmax values of esomeprazole were slightly higher (13%) in females than in males at steady state when dosed orally. This increase in exposure is not considered clinically relevant.

Patients with Renal Impairment

The pharmacokinetics of esomeprazole magnesium in patients with renal impairment are not expected to be altered relative to healthy subjects as less than 1% of esomeprazole is excreted unchanged in urine.

Patients with Hepatic Impairment

The steady state pharmacokinetics of esomeprazole obtained after administration of esomeprazole magnesium delayed-release capsules 40 mg orally once daily to patients with mild (Child-Pugh Class A, n=4), moderate (Child-Pugh Class B, n=4), and severe (Child-Pugh Class C, n=4) hepatic impairment were compared to those obtained in 36 male and female GERD patients with normal liver function. In patients with mild and moderate hepatic impairment, the AUCs were within the range that could be expected in patients with normal liver function. In patients with severe hepatic impairment the AUCs were 2 to 3 times higher than in the patients with normal liver function [see Use in Specific Populations (8.6)].

Drug Interaction Studies

Effect of Esomeprazole/Omeprazole on Other Drugs

In vitro and in vivo studies have shown that esomeprazole is not likely to inhibit CYPs 1A2, 2A6, 2C9, 2D6, 2E1 and 3A4.

Antiretrovirals

For some antiretroviral drugs, such as rilpivirine, atazanavir and nelfinavir, decreased serum concentrations have been reported when given together with omeprazole [see Drug Interactions (7)].

Rilpivirine: Following multiple doses of rilpivirine (150 mg, daily) and omeprazole (20 mg, daily), AUC was decreased by 40%, Cmax by 40%, and Cmin by 33% for rilpivirine [see Contraindications (4)].

Nelfinavir: Following multiple doses of nelfinavir (1250 mg, twice daily) and omeprazole (40 mg daily), AUC was decreased by 36% and 92%, Cmax by 37% and 89% and Cmin by 39% and 75% respectively for nelfinavir and M8.

Atazanavir: Following multiple doses of atazanavir (400 mg, daily) and omeprazole (40 mg, daily, 2 hours before atazanavir), AUC was decreased by 94%, Cmax by 96%, and Cmin by 95%.

Saquinavir: Following multiple dosing of saquinavir/ritonavir (1000/100 mg) twice daily for 15 days with omeprazole 40 mg daily co-administered days 11 to 15. The AUC was increased by 82%, Cmax by 75%, and Cmin by 106%. The mechanism behind this interaction is not fully elucidated.

Clopidogrel

In a crossover study, healthy subjects were administered clopidogrel (300 mg loading dose followed by 75 mg per day as the maintenance dosage for 28 days) alone and with esomeprazole (40 mg orally once daily at the same time as clopidogrel) for 29 days. Exposure to the active metabolite of clopidogrel was reduced by 35% to 40% over this time period when clopidogrel and esomeprazole were administered together. Pharmacodynamic parameters were also measured and demonstrated that the change in inhibition of platelet aggregation was related to the change in the exposure to clopidogrel active metabolite [see Warnings and Precautions (5.7) and Drug Interactions (7)].

Mycophenolate Mofetil

Administration of omeprazole 20 mg twice daily for 4 days and a single 1000 mg dose of MMF approximately one hour after the last dose of omeprazole to 12 healthy subjects in a cross-over study resulted in a 52% reduction in the Cmax and 23% reduction in the AUC of MPA [see Drug Interactions (7)].

Cilostazol

Omeprazole acts as an inhibitor of CYP2C19. Omeprazole, given in doses of 40 mg daily for one week to 20 healthy subjects in cross-over study, increased Cmax and AUC of cilostazol by 18% and 26% respectively. The Cmax and AUC of one of the active metabolites, 3,4-dihydro-cilostazol, which has 4 to 7 times the activity of cilostazol, were increased by 29% and 69%, respectively. Co-administration of cilostazol with omeprazole is expected to increase concentrations of cilostazol and the above mentioned active metabolite [see Drug Interactions (7)].

Diazepam

Co-administration of esomeprazole 30 mg and diazepam, a CYP2C19 substrate, resulted in a 45% decrease in clearance of diazepam. Increased plasma levels of diazepam were observed 12 hours after dosing and onwards. However, at that time, the plasma levels of diazepam were below the therapeutic interval, and thus this interaction is unlikely to be of clinical relevance.

Digoxin

Concomitant administration of omeprazole 20 mg once daily and digoxin in healthy subjects increased the bioavailability of digoxin by 10% (30% in two subjects) [see Drug Interactions (7)].

Other Drugs

Concomitant administration of esomeprazole and either naproxen (non-selective NSAID) did not identify any clinically relevant changes in the pharmacokinetic profiles of these NSAIDs.

Effect of Other Drugs on Esomeprazole/Omeprazole

St. John’s Wort

In a cross-over study in 12 healthy male subjects, St. John’s Wort (300 mg three times daily for 14 days) significantly decreased the systemic exposure of omeprazole in CYP2C19 poor metabolizers (Cmax and AUC both decreased by 38%) and extensive metabolizers (Cmax and AUC decreased by 50% and 44%, respectively) [see Drug Interactions (7)].

Voriconazole

Concomitant administration of omeprazole and voriconazole (a combined inhibitor of CYP2C19 and CYP3A4) resulted in more than doubling of the omeprazole exposure. When voriconazole (400 mg every 12 hours for one day, followed by 200 mg once daily for 6 days) was given with omeprazole (40 mg once daily for 7 days) to healthy subjects, the steady-state Cmax and AUC0-24 of omeprazole significantly increased: an average of 2 times (90% CI: 1.8, 2.6) and 4 times (90% CI: 3.3, 4.4), respectively, as compared to when omeprazole was given without voriconazole [see Drug Interactions (7)].

Other Drugs

Co-administration of esomeprazole with oral contraceptives, diazepam, phenytoin, quinidine, naproxen (non-selective NSAID) did not seem to change the pharmacokinetic profile of esomeprazole. 

Esomeprazole magnesium, amoxicillin, and clarithromycin triple therapy has been shown to be active against most strains of Helicobacter pylori (H. pylori) in vitro and in clinical infections [see Indications and Usage (1) and Clinical Studies (14)].

Helicobacter pylori: Susceptibility testing of H. pylori isolates was performed for amoxicillin and clarithromycin using agar dilution methodology, and minimum inhibitory concentrations (MICs) were determined.

Pretreatment Resistance: Clarithromycin pretreatment resistance rate (MIC ≥ 1 mcg/mL) to H. pylori was 15% (66/445) at baseline in all treatment groups combined. A total of > 99% (394/395) of patients had H. pylori isolates that were considered to be susceptible (MIC ≤ 0.25 mcg/mL) to amoxicillin at baseline. One patient had a baseline H. pylori isolate with an amoxicillin MIC = 0.5 mcg/mL.

Clarithromycin Susceptibility Test Results and Clinical/Bacteriologic Outcomes: The baseline H. pylori clarithromycin susceptibility results and the H. pylori eradication results at the Day 38 visit are shown in Table 10:

Table 10: Clarithromycin Susceptibility Test Results and Clinical/Bacteriological Outcomes1 for Triple Therapy Esomeprazole Magnesium Delayed-Release Capsules 40 mg once daily, Amoxicillin 1000 mg twice daily and Clarithromycin 500 mg twice daily for 10 days)

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="597.037"> <colgroup> <col width="30.3853865003342%"/> <col width="29.583426152818%"/> <col width="8.1866785475607%"/> <col width="6.35999108932947%"/> <col width="8.60993539763867%"/> <col width="16.874582312319%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" valign="top"><span class="Bold">Clarithromycin Pretreatment Results</span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold"><span class="Italics">H. pylori</span> negative (Eradicated)</span> <br/> </td><td align="center" class="Rrule" colspan="4" valign="top"><span class="Bold"><span class="Italics">H. pylori</span> positive (Not Eradicated)</span> <br/> <span class="Bold">Post-treatment susceptibility results</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"> <br/> </td><td class="Rrule" valign="top"> <br/> </td><td class="Rrule" valign="top">S<span class="Sup">2</span> <br/> </td><td class="Rrule" valign="top">I<span class="Sup">2</span> <br/> </td><td class="Rrule" valign="top">R<span class="Sup">2</span> <br/> </td><td class="Rrule" valign="top">No MIC<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">Susceptible<span class="Sup">2</span>            182<br/> </td><td class="Rrule" valign="top">162<br/> </td><td class="Rrule" valign="top">4<br/> </td><td class="Rrule" valign="top">0<br/> </td><td class="Rrule" valign="top">2<br/> </td><td class="Rrule" valign="top">14<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">Intermediate<span class="Sup">2</span>           1<br/> </td><td class="Rrule" valign="top">1<br/> </td><td class="Rrule" valign="top">0<br/> </td><td class="Rrule" valign="top">0<br/> </td><td class="Rrule" valign="top">0<br/> </td><td class="Rrule" valign="top">0<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top">Resistant<span class="Sup">2</span>                 29<br/> </td><td class="Rrule" valign="top">13<br/> </td><td class="Rrule" valign="top">1<br/> </td><td class="Rrule" valign="top">0<br/> </td><td class="Rrule" valign="top">13<br/> </td><td class="Rrule" valign="top">2<br/> </td> </tr> </tbody> </table></div>

1. Includes only patients with pretreatment and post-treatment clarithromycin susceptibility test results

2. Susceptible (S) MIC ≤ 0.25 mcg/mL, Intermediate (I) MIC = 0.5 mcg/mL, Resistant (R) MIC ≥ 1.0 mcg/mL

Patients not eradicated of H. pylori following triple therapy with esomeprazole magnesium, amoxicillin and clarithromycin will likely have clarithromycin resistant H. pylori isolates. Therefore, clarithromycin susceptibility testing should be done, when possible. Patients with clarithromycin resistant H. pylori should not be re-treated with a clarithromycin-containing regimen.

Amoxicillin Susceptibility Test Results and Clinical/Bacteriological Outcomes:

In patients treated with esomeprazole magnesium, amoxicillin and clarithromycin in clinical trials, 83% (176/212) of the patients who had pretreatment amoxicillin susceptible MICs (≤ 0.25 mcg/mL) were eradicated of H. pylori, and 17% (36/212) were not eradicated of H. pylori. Of the 36 patients who were not eradicated of H. pylori, 16 had no post-treatment susceptibility test results and 20 had post-treatment H. pylori isolates with amoxicillin susceptible MICs. Fifteen of the patients who were not eradicated of H. pylori also had post-treatment H. pylori isolates with clarithromycin resistant MICs. There were no patients with H. pylori isolates who developed treatment emergent resistance to amoxicillin.

Susceptibility Test for Helicobacter pylori: For susceptibility testing information about Helicobacter pylori, see Microbiology section in prescribing information for clarithromycin and amoxicillin.

Effects on Gastrointestinal Microbial Ecology: Decreased gastric acidity due to any means, including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with PPIs may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile in hospitalized patients. 

CYP2C19, a polymorphic enzyme, is involved in the metabolism of esomeprazole. The CYP2C19*1 allele is fully functional while the CYP2C19*2 and *3 alleles are nonfunctional. There are other alleles associated with no or reduced enzymatic function. Patients carrying two fully functional alleles are extensive metabolizers and those carrying two loss-of-function alleles are poor metabolizers. The systemic exposure to esomeprazole varies with a patient’s metabolism status: poor metabolizers > intermediate metabolizers > extensive metabolizers. Approximately 3% of Caucasians and 15 to 20% of Asians are CYP2C19 poor metabolizers.

Systemic esomeprazole exposures were modestly higher (approximately 17%) in CYP2C19 intermediate metabolizers (IM; n=6) compared to extensive metabolizers (EM; n=17) of CYP2C19. Similar pharmacokinetic differences were noted across these genotypes in a study of Chinese healthy subjects that included 7 EMs and 11 IMs. There is very limited pharmacokinetic information for poor metabolizers (PM) from these studies.

At steady state following once daily administration of esomeprazole 40 mg, the ratio of AUC in poor metabolizers to AUC in the rest of the population (EMs) is approximately 1.5. This change in exposure is not considered clinically meaningful. 

The carcinogenic potential of esomeprazole magnesium was assessed using studies of omeprazole, of which esomeprazole is an enantiomer. In two 24-month oral carcinogenicity studies in rats, omeprazole at daily doses of 1.7, 3.4, 13.8, 44, and 140.8 mg/kg/day (about 0.4 to 34 times the human dose of 40 mg/day expressed on a body surface area basis) produced gastric ECL cell carcinoids in a dose-related manner in both male and female rats; the incidence of this effect was markedly higher in female rats, which had higher blood levels of omeprazole. Gastric carcinoids seldom occur in the untreated rat. In addition, ECL cell hyperplasia was present in all treated groups of both sexes. In one of these studies, female rats were treated with 13.8 mg omeprazole/kg/day (about 3.4 times the human dose of 40 mg/day on a body surface area basis) for 1 year, then followed for an additional year without the drug. No carcinoids were seen in these rats. An increased incidence of treatment-related ECL cell hyperplasia was observed at the end of 1 year (94% treated vs. 10% controls). By the second year the difference between treated and control rats was much smaller (46% vs. 26%) but still showed more hyperplasia in the treated group. Gastric adenocarcinoma was seen in one rat (2%). No similar tumor was seen in male or female rats treated for 2 years. For this strain of rat no similar tumor has been noted historically, but a finding involving only one tumor is difficult to interpret. A 78-week mouse carcinogenicity study of omeprazole did not show increased tumor occurrence, but the study was not conclusive.

Esomeprazole was negative in the Ames mutation test, in the in vivo rat bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test. Esomeprazole, however, was positive in the in vitro human lymphocyte chromosome aberration test. Omeprazole was positive in the in vitro human lymphocyte chromosome aberration test, the in vivo mouse bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test.

The potential effects of esomeprazole on fertility and reproductive performance were assessed using omeprazole studies. Omeprazole at oral doses up to 138 mg/kg/day in rats (about 34 times the human dose of 40 mg/day on a body surface area basis) was found to have no effect on reproductive performance of parental animals.

Reproduction Studies

Reproduction studies have been performed in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at oral doses up to 86 mg/kg/day (about 42 times an oral human dose of 40 mg on a body surface area basis) and have revealed no evidence of impaired fertility or harm to the fetus due to esomeprazole [see Use in Specific Populations (8.1)].

Juvenile Animal Study

A 28-day toxicity study with a 14-day recovery phase was conducted in juvenile rats with esomeprazole magnesium at doses of 70 to 280 mg /kg/day (about 17 to 68 times a daily oral human dose of 40 mg on a body surface area basis). An increase in the number of deaths at the high dose of 280 mg/kg/day was observed when juvenile rats were administered esomeprazole magnesium from postnatal day 7 through postnatal day 35. In addition, doses equal to or greater than 140 mg/kg/day (about 34 times a daily oral human dose of 40 mg on a body surface area basis), produced treatment-related decreases in body weight (approximately 14%) and body weight gain, decreases in femur weight and femur length, and affected overall growth. Comparable findings described above have also been observed in this study with another esomeprazole salt, esomeprazole strontium, at equimolar doses of esomeprazole. 

The healing rates of esomeprazole magnesium delayed-release capsules 40 mg, esomeprazole magnesium delayed-release capsules 20 mg, and omeprazole delayed-release capsules 20 mg (the approved dose for this indication) once daily were evaluated in adult patients with endoscopically diagnosed EE in four multicenter, double-blind, randomized studies. The healing rates at Weeks 4 and 8 were evaluated and are shown in Table 11:

Table 11: EE Healing Rate (Life-Table Analysis) in Adults with EE Treated with Esomeprazole Magnesium Delayed-Release Capsules or Omeprazole Delayed-Release Capsules Once Daily in Four Clinical Studies

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="626.43"> <colgroup> <col width="14.6496815286624%"/> <col width="16.7728237791932%"/> <col width="20.1698513800425%"/> <col width="14.4373673036093%"/> <col width="14.4373673036093%"/> <col width="19.5329087048832%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle"><span class="Bold">Study</span> <br/> </td><td class="Rrule" rowspan="2" valign="middle"><span class="Bold">No. of Patients</span> <br/> </td><td class="Rrule" rowspan="2" valign="middle"><span class="Bold">Treatment Group</span> <br/> </td><td class="Rrule" colspan="2" valign="top"><span class="Bold">EE Healing Rates</span> <br/> </td><td class="Rrule" valign="top"><span class="Bold">Significance Level<span class="Sup">1</span></span> <br/> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Week 4</span> <br/> </td><td class="Rrule" valign="middle"><span class="Bold">Week 8</span> <br/> </td><td class="Rrule" valign="top"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle">1<br/> </td><td align="center" class="Rrule" valign="middle">588<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">68.7%<br/> </td><td align="center" class="Rrule" valign="middle">90.6%<br/> </td><td class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">588<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">69.5%<br/> </td><td align="center" class="Rrule" valign="middle">88.3%<br/> </td><td class="Rrule" valign="top"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" rowspan="3" valign="middle">2<br/> </td><td align="center" class="Rrule" valign="middle">654<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">75.9%<br/> </td><td align="center" class="Rrule" valign="middle">94.1%<br/> </td><td class="Rrule" valign="top">p &lt; 0.001<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">656<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">70.5%<br/> </td><td align="center" class="Rrule" valign="middle">89.9%<br/> </td><td class="Rrule" valign="top">p &lt; 0.05<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">650<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.7%<br/> </td><td align="center" class="Rrule" valign="middle">86.9%<br/> </td><td class="Rrule" valign="top"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle">3<br/> </td><td align="center" class="Rrule" valign="middle">576<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">71.5%<br/> </td><td align="center" class="Rrule" valign="middle">92.2%<br/> </td><td class="Rrule" valign="top">N.S.<br/> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">572<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">68.6%<br/> </td><td align="center" class="Rrule" valign="middle">89.8%<br/> </td><td class="Rrule" valign="top"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle">4<br/> </td><td align="center" class="Rrule" valign="middle">1216<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">81.7%<br/> </td><td align="center" class="Rrule" valign="middle">93.7%<br/> </td><td class="Rrule" valign="middle">p &lt; 0.001<br/> </td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule" valign="middle">1209<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">68.7%<br/> </td><td align="center" class="Rrule" valign="middle">84.2%<br/> </td><td class="Rrule" valign="top"> <br/> </td> </tr> </tbody> </table></div>

 N.S.= not significant (p > 0.05) 

1.     log-rank test vs. omeprazole 20 mg

In these same studies of patients with EE, sustained heartburn resolution and time to sustained heartburn resolution were evaluated and are shown in Table 12:

Table 12: Sustained Resolution1 of Heartburn in Adults with EE Treated with Esomeprazole Magnesium Delayed-Release Capsules or Omeprazole Delayed-Release Capsules Once Daily in Four Clinical Studies

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="0"> <colgroup> <col width="9.25925925925926%"/> <col width="10.1851851851852%"/> <col width="32.4074074074074%"/> <col width="16.0493827160494%"/> <col width="16.0493827160494%"/> <col width="16.0493827160494%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle"><span class="Bold">Study</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">No. of Patients</span> <br/> </td><td class="Rrule" rowspan="2" valign="middle"><span class="Bold">Treatment Group</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Cumulative Percent<span class="Sup">2</span></span> <br/> </td><td class="Rrule" valign="middle"><span class="Bold">with Sustained Resolution</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">Significance Level<span class="Sup">3</span></span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Day 14</span> <br/> </td><td class="Rrule" valign="middle"><span class="Bold">Day 28</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">1<br/> </td><td align="center" class="Rrule" valign="middle">573<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.3%<br/> </td><td align="center" class="Rrule" valign="middle">72.7%<br/> </td><td class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"> <br/> </td><td align="center" class="Rrule" valign="middle">555<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.1%<br/> </td><td align="center" class="Rrule" valign="middle">70.9%<br/> </td><td class="Rrule" valign="top"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">2<br/> </td><td align="center" class="Rrule" valign="middle">621<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium<br/>40 mg<br/> </td><td align="center" class="Rrule" valign="middle">64.8%<br/> </td><td align="center" class="Rrule" valign="middle">74.2%<br/> </td><td class="Rrule" valign="middle">p &lt;0.001<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"> <br/> </td><td align="center" class="Rrule" valign="middle">620<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">62.9%<br/> </td><td align="center" class="Rrule" valign="middle">70.1%<br/> </td><td class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"> <br/> </td><td align="center" class="Rrule" valign="middle">626<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">56.5%<br/> </td><td align="center" class="Rrule" valign="middle">66.6%<br/> </td><td class="Rrule" valign="top"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">3<br/> </td><td align="center" class="Rrule" valign="middle">568<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">65.4%<br/> </td><td align="center" class="Rrule" valign="middle">73.9%<br/> </td><td class="Rrule" valign="middle">N.S.<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">551<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">65.5%<br/> </td><td align="center" class="Rrule" valign="middle">73.1%<br/> </td><td class="Rrule" valign="middle"> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">4<br/> </td><td align="center" class="Rrule" valign="middle">1187<br/> </td><td class="Rrule" valign="middle">Esomeprazole magnesium 40 mg<br/> </td><td align="center" class="Rrule" valign="middle">67.6%<br/> </td><td align="center" class="Rrule" valign="middle">75.1%<br/> </td><td class="Rrule" valign="middle">p &lt;0.001<br/> </td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule" valign="middle"> <br/> </td><td align="center" class="Rrule" valign="middle">1188<br/> </td><td class="Rrule" valign="middle">Omeprazole 20 mg<br/> </td><td align="center" class="Rrule" valign="middle">62.5%<br/> </td><td align="center" class="Rrule" valign="middle">70.8%<br/> </td><td class="Rrule" valign="middle"> <br/> </td> </tr> </tbody> </table></div>

1.   Defined as 7 consecutive days with no heartburn reported in daily patient diary.

2.   Defined as the cumulative proportion of patients who have reached the start of sustained resolution.

3.   log-rank test vs. omeprazole 20 mg.

N.S. = not significant (p > 0.05)

In these four studies, the range of median days to the start of sustained resolution (defined as 7 consecutive days with no heartburn) was 5 days for esomeprazole magnesium 40 mg, 7 to 8 days for esomeprazole magnesium 20 mg and 7 to 9 days for omeprazole 20 mg.

There are no comparisons of 40 mg of esomeprazole magnesium with 40 mg of omeprazole in clinical trials assessing either healing or symptomatic relief of EE.

Two multicenter, randomized, double-blind placebo-controlled 4-arm studies were conducted in adult patients with endoscopically confirmed, healed EE to evaluate esomeprazole magnesium delayed-release capsules 40 mg (n=174), 20 mg (n=180), 10 mg (n=168) or placebo (n=171) once daily over six months of treatment.

No additional clinical benefit was seen with esomeprazole magnesium 40 mg over esomeprazole magnesium 20 mg. Esomeprazole magnesium 40 mg once daily is not a recommended regimen for the maintenance of healing of EE in adults.

The percentages of patients that maintained healing of EE at the various time points are shown in the Figures 2 and 3:

Figure 2: Maintenance of Healing Rates of EE in Adults by Month (Study 177)

s= scheduled visit

Figure 3: Maintenance of EE Healing Rates in Adults by Month (Study 178)

s= scheduled visit

Patients remained in remission significantly longer and the number of recurrences of EE was significantly less in patients treated with esomeprazole magnesium compared to placebo.

In both studies, the proportion of patients on esomeprazole magnesium who remained in remission and were free of heartburn and other GERD symptoms was well differentiated from placebo.

In a third multicenter open label study of 808 patients treated for 12 months with esomeprazole magnesium 40 mg, the percentage of patients that maintained healing of EE was 93.7% for six months and 89.4% for one year. 

Two multicenter, randomized, double-blind, placebo-controlled studies were conducted in a total of 717 adult patients comparing four weeks of treatment with esomeprazole magnesium delayed-release capsules 20 mg or 40 mg once daily versus placebo for resolution of GERD symptoms. Patients had at least a 6-month history of heartburn episodes, no EE by endoscopy, and heartburn on at least four of the seven days immediately preceding randomization.

The percentage of patients that were symptom-free of heartburn was significantly higher in the esomeprazole magnesium groups compared to placebo at all follow-up visits (Weeks 1, 2, and 4).

No additional clinical benefit was seen with esomeprazole magnesium 40 mg over esomeprazole magnesium 20 mg. Esomeprazole magnesium 40 mg once daily is not a recommended regimen for the treatment of symptomatic GERD in adults.

The percent of patients symptom-free of heartburn by day are shown in the Figures 4 and 5:

Figure 4: Percent of Patients Symptom-Free of Heartburn by Day (Study 225)

Figure 5: Percent of Patients Symptom-Free of Heartburn by Day (Study 226)

In three European symptomatic GERD trials, esomeprazole magnesium 20 mg and 40 mg and omeprazole 20 mg were evaluated. No significant treatment related differences were seen. 

12 Years to 17 Years of Age

In a multicenter, randomized, double-blind, parallel-group study, 149 adolescent patients (12 to 17 years of age; 89 female; 124 Caucasian, 15 Black, 10 Other) with clinically diagnosed GERD were treated with esomeprazole magnesium delayed-release capsules 20 mg or 40 mg once daily for up to 8 weeks to evaluate safety and tolerability. Patients were not endoscopically characterized as to the presence or absence of EE.

Two multicenter, double-blind, placebo-controlled studies were conducted in adult patients at risk of developing gastric and/or duodenal ulcers associated with continuous use of non-selective and COX-2 selective NSAIDs. A total of 1429 patients were randomized across the 2 studies. Patients ranged in age from 19 to 89 (median age 66 years) with 71% female, 29% male; 83% Caucasian, 5% Black, 4% Asian, and 8% Others. At baseline, the patients in these studies were endoscopically confirmed not to have ulcers but were determined to be at risk for ulcer occurrence due to their age (at least 60 years) and/or history of a documented gastric or duodenal ulcer within the past 5 years. Patients receiving NSAIDs and treated with esomeprazole magnesium delayed-release capsules 20 mg or 40 mg once daily experienced significant reduction in gastric ulcer occurrences relative to placebo treatment at 26 weeks. See Table 13. No additional benefit was seen with esomeprazole magnesium 40 mg over esomeprazole magnesium 20 mg. Esomeprazole magnesium 40 mg once daily is not a recommended regimen for the risk reduction of NSAID-associated gastric ulcer in adults. These studies did not demonstrate significant reduction in the development of NSAID-associated duodenal ulcer due to the low incidence.

Table 13: Cumulative Percentage of Patients at Least 60 Years of Age Taking NSAIDS Without Gastric Ulcers at 26 Weeks in Two Randomized Placebo-Controlled Studies

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="0"> <colgroup> <col width="8.22657490735839%"/> <col width="18.4012705134992%"/> <col width="24.7538380095289%"/> <col width="48.6183165696136%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle">Study <br/> </td><td class="Rrule" valign="middle">No. of Patients <br/> </td><td class="Rrule" valign="middle">Treatment Group <br/> </td><td class="Rrule" valign="top">% of Patients Remaining Gastric Ulcer Free<span class="Sup">1</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top">1 <br/> </td><td class="Rrule" valign="top">191 <br/> <br/>194 <br/> <br/>184 <br/> </td><td class="Rrule" valign="top">Esomeprazole magnesium 20 mg Esomeprazole magnesium 40 mg Placebo <br/> </td><td class="Rrule" valign="top">95.4 <br/> <br/>96.7<br/> <br/>88.2 <br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top">2 <br/> </td><td class="Rrule" valign="top">267 <br/> <br/>271 <br/> <br/>257 <br/> </td><td class="Rrule" valign="top">Esomeprazole magnesium 20 mg Esomeprazole magnesium 40 mg <br/>Placebo <br/> </td><td class="Rrule" valign="top">94.7 <br/> <br/>95.3 <br/> <br/>83.3 <br/> </td> </tr> </tbody> </table></div>

1. %= Life Table Estimate. Significant difference from placebo (p<0.01).

Two multicenter, randomized, double-blind studies were conducted in adult patients using a 10-day treatment regimen of triple therapy (esomeprazole magnesium, amoxicillin and clarithromycin). The first study (191) compared esomeprazole magnesium delayed-release capsules 40 mg once daily in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily to esomeprazole magnesium delayed-release capsules 40 mg once daily plus clarithromycin 500 mg twice daily. The second study (193) compared esomeprazole magnesium delayed-release capsules 40 mg once daily in combination with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily to esomeprazole magnesium delayed-release capsules 40 mg once daily. H. pylori eradication rates, defined as at least two negative tests and no positive tests from CLOtest®, histology and/or culture, at 4 weeks post-therapy were significantly higher in the esomeprazole magnesium, amoxicillin and clarithromycin group than in the esomeprazole magnesium and clarithromycin group or the esomeprazole magnesium alone group. The results are shown in Table 14:

Table 14: H. pylori Eradication Rates at 4 Weeks after 10 Day Treatment Regimen % of Adult Patients Cured [95% Confidence Interval] (Number of Patients)

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0"> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle">Study </td><td class="Rrule" valign="middle"> Treatment Group</td><td class="Rrule" valign="middle">Per-Protocol1 </td><td class="Rrule" valign="middle"> Intent-to-Treat2</td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"> 191</td><td class="Rrule" valign="middle">Esomeprazole magnesium, amoxicillin and clarithromycin </td><td class="Rrule" valign="middle"> 84%3<br/>[78, 89]<br/>(n=196)<br/> </td><td class="Rrule" valign="middle">77%3<br/>[71, 82]<br/>(n=233)<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"> </td><td class="Rrule" valign="middle"> Esomeprazole magnesium and clarithromycin</td><td class="Rrule" valign="middle">55%<br/> [48, 62]<br/>(n=187)<br/> </td><td class="Rrule" valign="middle"> 52%<br/>[45, 59]<br/>(n=215)<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"> 193</td><td class="Rrule" valign="middle"> Esomeprazole magnesium, amoxicillin and clarithromycin</td><td class="Rrule" valign="middle">85%4<br/>[74, 93]<br/>(n=67)<br/> </td><td class="Rrule" valign="middle">78%4<br/>[67, 87]<br/>(n=74)<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle"> </td><td class="Rrule" valign="middle"> Esomeprazole magnesium</td><td class="Rrule" valign="middle"> 5%<br/>[0, 23]<br/>(n=22)<br/> </td><td class="Rrule" valign="middle"> 4%<br/>[0, 21]<br/>(n=24)<br/> </td> </tr> </tbody> </table></div>

The percentage of patients with a healed baseline duodenal ulcer by 4 weeks after the 10-day treatment regimen in the esomeprazole magnesium, amoxicillin and clarithromycin group was 75% (n=156) and 57% (n=60) respectively, in the 191 and 193 studies (per-protocol analysis). 

In a multicenter, open-label dose-escalation study of 21 adult patients (15 males and 6 females, 18 Caucasian and 3 Black, mean age of 56 years) with pathological hypersecretory conditions, such as Zollinger-Ellison Syndrome, esomeprazole magnesium significantly inhibited gastric acid secretion. The initial dosage of esomeprazole magnesium delayed-release capsules was 40 mg twice daily in 19 patients and 80 mg twice daily in 2 patients. Total daily doses ranging from 80 mg to 240 mg for 12 months maintained gastric acid output below the target levels of 10 mEq/h in patients without prior gastric acid-reducing surgery and below 5 mEq/hr in patients with prior gastric acid-reducing surgery. At the Month 12 final visit, 18/20 (90%) patients had Basal Acid Output (BAO) under satisfactory control (median BAO = 0.17 mmol/hr). Of the 18 patients evaluated with a starting dose of esomeprazole magnesium 40 mg twice daily, 13 (72%) had their BAO controlled with the original dosing regimen at the final visit. See Table 15.

Table 15: Adequate Acid Suppression at Final Visit by Dosage Regimen in Adult Patients with Pathological Hypersecretory Conditions

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="621.775"> <colgroup> <col width="50%"/> <col width="50%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" valign="top"><span class="Bold">Esomeprazole magnesium dose at the Month 12 visit </span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold">BAO under adequate control at the Month 12 visit (N=20)<span class="Italics"><span class="Sup">1</span></span></span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">40 mg twice daily <br/> </td><td align="center" class="Rrule" valign="middle">13/15 <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="top">80 mg twice daily <br/> </td><td align="center" class="Rrule" valign="top">4/4 <br/> </td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule" valign="top">80 mg three times daily <br/> </td><td align="center" class="Rrule" valign="top">1/1 <br/> </td> </tr> </tbody> </table></div>

1. One patient was not evaluated.

Esomeprazole magnesium delayed-release capsules, USP 20 mg, are light yellow to brown colored enteric coated pellets filled in size "4" hard gelatin capsule, opaque dark blue cap & opaque dark blue body printed "ESOM" on cap and "20" on the body in white ink. They are supplied as follows:

{ "type": "p", "children": [], "text": "Esomeprazole magnesium delayed-release capsules, USP 20 mg, are light yellow to brown colored enteric coated pellets filled in size \"4\" hard gelatin capsule, opaque dark blue cap & opaque dark blue body printed \"ESOM\" on cap and \"20\" on the body in white ink. They are supplied as follows:" }

NDC 67877-571-30 bottles of 30

{ "type": "p", "children": [], "text": "NDC 67877-571-30 bottles of 30" }

NDC 67877-571-90 bottles of 90

{ "type": "p", "children": [], "text": "NDC 67877-571-90 bottles of 90" }

NDC 67877-571-05 bottles of 500

{ "type": "p", "children": [], "text": "NDC 67877-571-05 bottles of 500" }

NDC 67877-571-10 bottles of 1000

{ "type": "p", "children": [], "text": "NDC 67877-571-10 bottles of 1000" }

NDC 67877-571-38 Carton of 100 (10 x 10 Unit-dose Capsules)

{ "type": "p", "children": [], "text": "NDC 67877-571-38 Carton of 100 (10 x 10 Unit-dose Capsules)" }

Esomeprazole magnesium delayed release capsules USP, 40 mg, are light yellow to brown colored enteric coated pellets filled in size "3" hard gelatin capsule, opaque dark blue cap & opaque dark blue body printed "ESOM" on cap and "40" on the body in white ink. They are supplied as follows:

{ "type": "p", "children": [], "text": "Esomeprazole magnesium delayed release capsules USP, 40 mg, are light yellow to brown colored enteric coated pellets filled in size \"3\" hard gelatin capsule, opaque dark blue cap & opaque dark blue body printed \"ESOM\" on cap and \"40\" on the body in white ink. They are supplied as follows:" }

NDC 67877-572-30 bottles of 30

{ "type": "p", "children": [], "text": "NDC 67877-572-30 bottles of 30" }

NDC 67877-572-90 bottles of 90

{ "type": "p", "children": [], "text": "NDC 67877-572-90 bottles of 90" }

NDC 67877-572-05 bottles of 500

{ "type": "p", "children": [], "text": "NDC 67877-572-05 bottles of 500" }

NDC 67877-572-10 bottles of 1000

{ "type": "p", "children": [], "text": "NDC 67877-572-10 bottles of 1000" }

NDC 67877-572-38 Carton of 100 (10 x 10 Unit-dose Capsules)

{ "type": "p", "children": [], "text": "NDC 67877-572-38 Carton of 100 (10 x 10 Unit-dose Capsules)" }

Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F). [See USP Controlled Room Temperature]. Keep esomeprazole magnesium delayed-release capsules, USP container tightly closed. Dispense in a tight container if the esomeprazole magnesium delayed-release capsules product package is subdivided.

{ "type": "p", "children": [], "text": "Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F). [See USP Controlled Room Temperature]. Keep esomeprazole magnesium delayed-release capsules, USP container tightly closed. Dispense in a tight container if the esomeprazole magnesium delayed-release capsules product package is subdivided." }

Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use).

{ "type": "p", "children": [], "text": "Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use)." }

Acute Tubulointerstitial Nephritis

{ "type": "p", "children": [], "text": "\nAcute Tubulointerstitial Nephritis \n" }

Advise the patient or caregiver to call the patient’s healthcare provider immediately if they experience signs and/or symptoms associated with suspected acute TIN [see Warnings and Precautions (5.2)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to call the patient’s healthcare provider immediately if they experience signs and/or symptoms associated with suspected acute TIN [see Warnings and Precautions (5.2)]." }

Clostridium difficile-Associated Diarrhea

{ "type": "p", "children": [], "text": "\nClostridium difficile-Associated Diarrhea \n" }

Advise the patient or caregiver to immediately call the patient’s healthcare provider if they experience diarrhea that does not improve [see Warnings and Precautions (5.3)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to immediately call the patient’s healthcare provider if they experience diarrhea that does not improve [see Warnings and Precautions (5.3)]." }

Bone Fracture

{ "type": "p", "children": [], "text": "\nBone Fracture \n" }

Advise the patient or caregiver to report any fractures, especially of the hip, wrist or spine, to the patient’s healthcare provider [see Warnings and Precautions (5.4)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any fractures, especially of the hip, wrist or spine, to the patient’s healthcare provider [see Warnings and Precautions (5.4)]." }

Severe Cutaneous Adverse Reactions

{ "type": "p", "children": [], "text": "\nSevere Cutaneous Adverse Reactions\n" }

Advise the patient or caregiver to discontinue esomeprazole magnesium and immediately call the patient’s healthcare provider for at first appearance of a severe cutaneous adverse reaction or other sign of hypersensitivity signs or symptoms associated with Severe Cutaneous Adverse Reactions[see Warnings and Precautions (5.5)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to discontinue esomeprazole magnesium and immediately call the patient’s healthcare provider for at first appearance of a severe cutaneous adverse reaction or other sign of hypersensitivity signs or symptoms associated with Severe Cutaneous Adverse Reactions[see Warnings and Precautions (5.5)].\n" }

Cutaneous and Systemic Lupus Erythematosus

{ "type": "p", "children": [], "text": "\nCutaneous and Systemic Lupus Erythematosus \n" }

Advise the patient or caregiver to immediately call the patient’s healthcare provider for any new or worsening of symptoms associated with cutaneous or systemic lupus erythematosus [see Warnings and Precautions (5.6)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to immediately call the patient’s healthcare provider for any new or worsening of symptoms associated with cutaneous or systemic lupus erythematosus [see Warnings and Precautions (5.6)].\n" }

Cyanocobalamin (Vitamin B-12)

{ "type": "p", "children": [], "text": "\nCyanocobalamin (Vitamin B-12) \n" }

Deficiency Advise the patient or caregiver to report any clinical symptoms that may be associated with cyanocobalamin deficiency to the patient’s healthcare provider if they have been receiving esomeprazole magnesium for longer than 3 years [see Warnings and Precautions (5.8)].

{ "type": "p", "children": [], "text": "Deficiency Advise the patient or caregiver to report any clinical symptoms that may be associated with cyanocobalamin deficiency to the patient’s healthcare provider if they have been receiving esomeprazole magnesium for longer than 3 years [see Warnings and Precautions (5.8)].\n" }

Hypomagnesemia and Mineral Metabolism

{ "type": "p", "children": [], "text": "\nHypomagnesemia and Mineral Metabolism \n" }

Advise the patient or caregiver to report any clinical symptoms that may be associated with hypomagnesemia, hypocalcemia, and/or hypokalemia to the patient’s healthcare provider, if they have been receiving esomeprazole magnesium for at least 3 months[see Warnings and Precautions (5.9)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any clinical symptoms that may be associated with hypomagnesemia, hypocalcemia, and/or hypokalemia to the patient’s healthcare provider, if they have been receiving esomeprazole magnesium for at least 3 months[see Warnings and Precautions (5.9)].\n" }

Drug Interactions

{ "type": "p", "children": [], "text": "\nDrug Interactions \n" }

Advise the patient or caregiver to report to their healthcare provider if starting treatment with rilpivirine-containing products, clopidogrel, St. John’s Wort or rifampin; or, if they take high-dose methotrexate [see Contraindications (4), Warnings and Precautions (5.7, 5.10, 5.12)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report to their healthcare provider if starting treatment with rilpivirine-containing products, clopidogrel, St. John’s Wort or rifampin; or, if they take high-dose methotrexate [see Contraindications (4), Warnings and Precautions (5.7, 5.10, 5.12)]. \n" }

Administration

{ "type": "p", "children": [], "text": "\nAdministration \n" }

{ "type": "ul", "children": [ "Take esomeprazole magnesium delayed-release capsules at least one hour before meals. ", "Antacids may be used concomitantly with esomeprazole magnesium. ", "Swallow esomeprazole magnesium delayed-release capsules whole; do not chew or crush the capsules. ", "For patients who have difficulty swallowing capsules, esomeprazole magnesium delayed-release capsules can be opened, and the contents sprinkled on applesauce. Use with other foods is not recommended. \nAdd one tablespoon of applesauce to an empty bowl. The applesauce used should not be hot and should be soft enough to be swallowed without chewing. \nOpen the esomeprazole magnesium delayed-release capsule and carefully empty the granules inside the capsule onto the applesauce. \nMix the granules with the applesauce. \nAdminister the mixture immediately. Do not chew or crush the granules.\nDiscard any remaining mixture. Do not store the mixture for future use. \n\n", "Esomeprazole magnesium delayed-release capsules can also be administered via a nasogastric tube, as described in the Instructions for Use." ], "text": "" }

For Medication Guide, please visit:

{ "type": "p", "children": [], "text": "For Medication Guide, please visit:" }

http://www.ascendlaboratories.com/mg/esomemgdrcaptri.pdf

{ "type": "p", "children": [], "text": "http://www.ascendlaboratories.com/mg/esomemgdrcaptri.pdf" }

Manufactured by:

{ "type": "p", "children": [], "text": "\nManufactured by:\n" }

Alkem Laboratories Ltd.,

{ "type": "p", "children": [], "text": "Alkem Laboratories Ltd.," }

Mumbai- 400 013, INDIA.

{ "type": "p", "children": [], "text": "Mumbai- 400 013, INDIA." }

Distributed by:

{ "type": "p", "children": [], "text": "\nDistributed by:\n" }

Ascend Laboratories, LLC

{ "type": "p", "children": [], "text": "Ascend Laboratories, LLC" }

Bedminster, NJ 07921

{ "type": "p", "children": [], "text": "Bedminster, NJ 07921" }

Brands listed are the trademarks of their respective owners.

{ "type": "p", "children": [], "text": "Brands listed are the trademarks of their respective owners." }

Esomeprazole Magnesium Delayed-Release Capsules, USP for oral use

{ "type": "p", "children": [], "text": "\nEsomeprazole Magnesium Delayed-Release Capsules, USP for oral use\n" }

(es ″ oh mep′ ra zole mag nee′ zee um)

{ "type": "p", "children": [], "text": "\n(es ″ oh mep′ ra zole mag nee′ zee um)\n" }

What is the most important information I should know about esomeprazole magnesium delayed-release capsules?

{ "type": "p", "children": [], "text": "\nWhat is the most important information I should know about esomeprazole magnesium delayed-release capsules?\n" }

Esomeprazole magnesium delayed-release capsules may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor.

{ "type": "p", "children": [], "text": "\nEsomeprazole magnesium delayed-release capsules may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor.\n" }

Esomeprazole magnesium delayed-release capsules can cause serious side effects, including:

{ "type": "p", "children": [], "text": "\nEsomeprazole magnesium delayed-release capsules can cause serious side effects, including:\n" }

{ "type": "ul", "children": [ "\n  A type of kidney problem (acute tubulointerstitial nephritis). Some people who take proton pump inhibitor (PPI) medicines, including Esomeprazole magnesium, may develop a kidney problem called acute tubulointerstitial nephritis that can happen at any time during treatment with Esomeprazole magnesium. Call your doctor right away if you have a decrease in the amount that you urinate or if you have blood in your urine. \n \n\n", "\nDiarrhea caused by an infection (Clostridium difficile) in your intestines. Call your doctor right away if you have watery stools or stomach pain that does not go away. You may or may not have a fever.\n", "  Bone fractures (hip, wrist, or spine). Bone fractures in the hip, wrist, or spine may happen in people who take multiple daily doses of PPI medicines and for a long period of time (a year or longer). Tell your doctor if you have a bone fracture, especially in the hip, wrist, or spine.\n\nTalk to your doctor about your risk of these serious side effects.\n\nEsomeprazole magnesium delayed-release capsules can have other serious side effects. See “What are the possible side effects of esomeprazole magnesium delayed-release capsules?”\n\n\n\nWhat is esomeprazole magnesium delayed-release capsules?\n\n\nA prescription medicine called a proton pump inhibitor (PPI) used to reduce the amount of acid in your stomach. Esomeprazole magnesium is used in adults for: \n", "4 to 8 weeks for the healing and symptom relief of acid-related damage to the esophagus (erosive esophagitis or EE). Your doctor may prescribe another 4 to 8 weeks of esomeprazole magnesium in patients whose EE does not heal. ", "maintaining healing of EE. ", "4 to 8 weeks to treat heartburn and other symptoms that happen with gastroesophageal reflux disease (GERD). ", "up to 6 months to reduce the risk of stomach ulcers in some people taking pain medicines called non-steroidal anti-inflammatory drugs (NSAIDs). ", "treating patients with a stomach infection (Helicobacter pylori) and a stomach ulcer, along with the antibiotics amoxicillin and clarithromycin. ", "the long-term treatment of conditions where your stomach makes too much acid, including Zollinger-Ellison Syndrome. Zollinger-Ellison Syndrome is a rare condition in which the stomach produces a more than normal amount of acid. \nEsomeprazole magnesium is used in children and adolescents 12 to 17 years of age for: \n", "4 to 8 weeks to heal EE. ", "4 weeks to treat heartburn and other symptoms that happen with GERD.\nIt is not known if esomeprazole magnesium is safe and effective in children under 1 month of age for the treatment of GERD with EE. It is not known if esomeprazole magnesium is safe and effective in children less than 1 year of age for the treatment of GERD symptoms. It is not known if esomeprazole magnesium is safe and effective in children to reduce the risk of stomach ulcers in children who take medicines called NSAIDs, to treat Helicobacter pylori stomach infection to lower the risk of a stomach ulcer returning, and to treat conditions where your stomach makes too much acid. \n\n\nDo not take esomeprazole magnesium if you are: \n\n", "allergic to esomeprazole magnesium, any other PPI medicine, or any of the ingredients in esomeprazole magnesium. See the end of this Medication Guide for a complete list of ingredients in esomeprazole magnesium. Tell your doctor right away or get emergency medical help if you get any of the following symptoms of an allergic reaction with esomeprazole magnesium: \n\no   rash\no   throat tightness\no   face swelling\no   difficulty breathing\n\n", "taking a medicine that contains rilpivirine (EDURANT, COMPLERA, ODEFSEY) used to treat HIV-1 (Human Immunodeficiency Virus).\n \n\n\nBefore taking esomeprazole magnesium, tell your doctor about all of your medical conditions, including if you: \n\n", "have low magnesium levels, low calcium levels and low potassium levels in your blood.", "have liver problems. ", "are pregnant or plan to become pregnant. It is not known if esomeprazole magnesium will harm your unborn baby. ", "are breastfeeding or planning to breastfeed. Esomeprazole magnesium may pass into your breast milk. Talk to your doctor about the best way to feed your baby if you take esomeprazole magnesium. \nTell your doctor about all of the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. \n\nEspecially tell your doctor if you take: clopidogrel (Plavix), methotrexate (Otrxup, Rasuvo, Trexall, XATMEP), digoxin (LANOXIN), rilpivirine (EDURANT), St. John’s Wort (Hypericum perforatum), or rifampin (Rimactane, Rifater, Rifamate).\n\n\nHow should I take esomeprazole magnesium? \n\n", "Take esomeprazole magnesium exactly as prescribed by your doctor. ", "Do not change your dose or stop esomeprazole magnesium without talking to your doctor. ", "Take esomeprazole magnesium at least 1 hour before a meal. ", "Antacids may be taken with esomeprazole magnesium. ", "Swallow esomeprazole magnesium capsules whole. Never chew or crush esomeprazole magnesium. \n", "If you have difficulty swallowing esomeprazole magnesium capsules, you may open the capsule and empty the granules into 1 tablespoon of applesauce. The applesauce used should not be hot and should be soft enough to swallow without chewing. Do not mix the esomeprazole magnesium granules with any other food. ", "Do not crush or chew the granules. Be sure to swallow the applesauce right away. Throw away any remaining mixture. Do not store it for later use. ", "If you forget to take a dose of esomeprazole magnesium, take it as soon as you remember. If it is almost time for your next dose, do not take the missed dose. Take the next dose on time. Do not take a double dose to make up for a missed dose. ", "If you take too much esomeprazole magnesium, call your doctor or local poison control center right away at 1-800-222-1222, or go to the nearest hospital emergency room. ", "See the Instructions for Use at the end of this Medication Guide for instructions how to mix and give esomeprazole magnesium delayed-release capsules through a nasogastric tube. \nWhat are the possible side effects of esomeprazole magnesium? \n\n\nEsomeprazole magnesium can cause serious side effects, including: \n\n", "\nSee “What is the most important information I should know about esomeprazole magnesium?” \n", "\nLow vitamin B-12 levels in your body can happen in people who have taken esomeprazole magnesium for a long time (more than 3 years). Tell your doctor if you have symptoms of low vitamin B-12 levels, including shortness of breath, lightheadedness, irregular heartbeat, muscle weakness, pale skin, feeling tired, mood changes, and tingling or numbness in the arms and legs. ", "\nLow magnesium levels in your body can happen in people who have taken esomeprazole magnesium for at least 3 months. Tell your doctor right away if you have symptoms of low magnesium levels, including seizures, dizziness, irregular heartbeat, jitteriness, muscle aches or weakness, and spasms of hands, feet or voice. ", "\nStomach growths (fundic gland polyps). People who take PPI medicines for a long time have an increased risk of developing a certain type of stomach growths called fundic gland polyps, especially after taking PPI medicines for more than 1 year. ", "\nSevere skin reactions. Esomeprazole magnesium can cause rare but severe skin reactions that may affect any part of your body. These serious skin reactions may need to be treated in a hospital and may be life threatening: \nSkin rash which may have blistering, peeling or bleeding on any part of your skin (including your lips, eyes, mouth, nose, genitals, hands or feet). \nYou may also have fever, chills, body aches, shortness of breath, or enlarged lymph nodes. \n\nStop taking esomeprazole magnesium and call your doctor right away. These symptoms may be the first sign of a severe skin reaction.   \nThe most common side effects of esomeprazole magnesium include: \n·       headache\n·       stomach (abdominal) pain\n·       diarrhea\n·       constipation\n·       nausea\n·       dry mouth\n·       gas\n\n These are not all the possible side effects of esomeprazole magnesium. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.\n\n\nHow should I store esomeprazole magnesium? \n\n", "Store esomeprazole magnesium at room temperature between 68°F to 77°F (20°C to 25°C). ", "Keep the container of esomeprazole magnesium closed tightly." ], "text": "" }

{ "type": "ul", "children": [ "\nCertain types of lupus erythematosus. Lupus erythematosus is an autoimmune disorder (the body’s immune cells attack other cells or organs in the body). Some people who take PPI medicines, including Esomeprazole magnesium, may develop certain types of lupus erythematosus or have worsening of the lupus they already have. Call your doctor right away if you have new or worsening joint pain or a rash on your cheeks or arms that gets worse in the sun. " ], "text": "" }

Keep esomeprazole magnesium and all medicines out of the reach of children.

{ "type": "p", "children": [], "text": "\nKeep esomeprazole magnesium and all medicines out of the reach of children. \n" }

General information about the safe and effective use of esomeprazole magnesium. 

{ "type": "p", "children": [], "text": "\nGeneral information about the safe and effective use of esomeprazole magnesium. " }

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use esomeprazole magnesium for a condition for which it was not prescribed. Do not give esomeprazole magnesium to other people, even if they have the same symptoms you have. It may harm them.

{ "type": "p", "children": [], "text": "Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use esomeprazole magnesium for a condition for which it was not prescribed. Do not give esomeprazole magnesium to other people, even if they have the same symptoms you have. It may harm them." }

You can ask your pharmacist or doctor for information about esomeprazole magnesium that is written for health professionals.

{ "type": "p", "children": [], "text": "You can ask your pharmacist or doctor for information about esomeprazole magnesium that is written for health professionals." }

What are the ingredients in esomeprazole magnesium delayed-release capsules, USP?

{ "type": "p", "children": [], "text": "\nWhat are the ingredients in esomeprazole magnesium delayed-release capsules, USP?\n" }

Active ingredient: esomeprazole magnesium trihydrate

{ "type": "p", "children": [], "text": "\nActive ingredient: esomeprazole magnesium trihydrate" }

Inactive ingredients in esomeprazole magnesium delayed-release capsules, USP (including the capsule shells): Colloidal silicon dioxide, hypromellose, magnesium stearate, meglumine, methacrylic acid and ethyl acrylate copolymer dispersion, mono & diglycerides, poloxamer, sugar spheres, talc and triethyl citrate.

{ "type": "p", "children": [], "text": "\nInactive ingredients in esomeprazole magnesium delayed-release capsules, USP (including the capsule shells): Colloidal silicon dioxide, hypromellose, magnesium stearate, meglumine, methacrylic acid and ethyl acrylate copolymer dispersion, mono & diglycerides, poloxamer, sugar spheres, talc and triethyl citrate. " }

The capsule shells and Imprinting Ink have the following inactive ingredients: Capsule shell: gelatin, FD & C Blue 1, FD & C Red 40, titanium dioxide, sodium lauryl sulphate and Imprinting Ink: potassium hydroxide, shellac, and titanium dioxide.

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This Medication Guide has been approved by the U.S. Food and Drug Administration.

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For Medication Guide, please visit:

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http://www.ascendlaboratories.com/mg/esomemgdrcaptri.pdf

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Manufactured by:

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Alkem Laboratories Ltd.,

{ "type": "p", "children": [], "text": "Alkem Laboratories Ltd.," }

Mumbai- 400 013, INDIA.

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Distributed by:

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Ascend Laboratories, LLC

{ "type": "p", "children": [], "text": "Ascend Laboratories, LLC" }

Bedminster, NJ 07921

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Revised: January, 2025

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Brands listed are the trademarks of their respective owners.

{ "type": "p", "children": [], "text": "Brands listed are the trademarks of their respective owners." }

Instructions for Use

{ "type": "p", "children": [], "text": "\nInstructions for Use\n" }

Esomeprazole Magnesium Delayed-Release Capsules, USP

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(es ″ oh mep′ ra zole mag nee′ zee um)

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Giving esomeprazole magnesium delayed-release capsules with water through a nasogastric tube (NG tube)

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Esomeprazole magnesium delayed-release capsules:

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{ "type": "ul", "children": [ "Open the capsule and empty the granules into a 60 mL catheter tipped syringe. Mix with 50 mL of water. Use only a catheter tipped syringe to give esomeprazole magnesium through a NG tube. ", "Replace the plunger and shake the syringe well for 15 seconds. Hold the syringe with the tip up and check for granules in the tip. ", "Do not give the granules if they have dissolved or have broken into pieces. ", "Attach the syringe to the NG tube. Give the medicine in the syringe through the NG tube into the stomach. ", "After giving the granules, flush the NG tube with more water." ], "text": "" }

This Instructions for Use has been approved by the U.S. Food and Drug Administration.

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Manufactured by:

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Alkem Laboratories Ltd.,

{ "type": "p", "children": [], "text": "Alkem Laboratories Ltd.," }

Mumbai- 400 013, INDIA.

{ "type": "p", "children": [], "text": "Mumbai- 400 013, INDIA." }

Distributed by:

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Ascend Laboratories, LLC

{ "type": "p", "children": [], "text": "Ascend Laboratories, LLC" }

Bedminster, NJ 07921

{ "type": "p", "children": [], "text": "Bedminster, NJ 07921" }

Revised: January, 2025

{ "type": "p", "children": [], "text": "\nRevised: January, 2025" }

PT2834-05/PT2835-05

{ "type": "p", "children": [], "text": "PT2834-05/PT2835-05" }

20mg Capsule Bottle Label 

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NDC 67877-571-30

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30 capsules 

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ESOMEPRAZOLE MAGNESIUM delayed-release capsules, USP for oral use

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Dispense the accompanying Medication guide to each patient. 

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40mg Capsule Bottle Label

{ "type": "p", "children": [], "text": "\n40mg Capsule Bottle Label\n" }

NDC 67877-572-90

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90 capsules

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ESOMEPRAZOLE MAGNESIUM delayed-release capsules, USP for oral use

{ "type": "p", "children": [], "text": "\nESOMEPRAZOLE MAGNESIUM delayed-release capsules, USP for oral use\n" }

Dispense the accompanying Medication guide to each patient.

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Adults

Esomeprazole magnesium for delayed-release oral suspension is indicated for the short-term treatment (4 to 8 weeks) in the healing and symptomatic resolution of diagnostically confirmed EE in adults. For those patients who have not healed after 4 to 8 weeks of treatment, an additional 4-to 8-week course of esomeprazole magnesium for delayed-release oral suspension may be considered.

Pediatric Patients 12 Years to 17 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for the short-term treatment (4 to 8 weeks) for the healing of EE in pediatric patients 12 years to 17 years of age.

Pediatric Patients 1 Year to 11 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for the short-term treatment (8 weeks) for the healing of EE in pediatric patients 1 year to 11 years of age.

Pediatric Patients 1 Month to Less Than 1 Year of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (up to 6 weeks) of EE due to acid-mediated GERD in pediatric patients 1 month to less than 1 year of age.

Esomeprazole magnesium for delayed-release oral suspension is indicated for the maintenance of healing of EE in adults. Controlled studies do not extend beyond 6 months.

Adults

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (4 to 8 weeks) of heartburn and other symptoms associated with GERD in adults.

Pediatric Patients 12 Years to 17 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (4 weeks) of heartburn and other symptoms associated with GERD in pediatric patients 12 years to 17 years of age.

Pediatric Patients 1 Year to 11 Years of Age

Esomeprazole magnesium for delayed-release oral suspension is indicated for short-term treatment (up to 8 weeks) of heartburn and other symptoms associated with GERD in pediatric patients 1 year to 11 years of age.

Esomeprazole magnesium for delayed-release oral suspension is indicated for the reduction in the occurrence of gastric ulcers associated with continuous NSAID therapy in adult patients at risk for developing gastric ulcers. Patients are considered to be at risk due to their age (60 years and older) and/or documented history of gastric ulcers. Controlled studies do not extend beyond 6 months.

Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

Triple Therapy

Esomeprazole magnesium for delayed-release oral suspension in combination with amoxicillin and clarithromycin is indicated for the treatment of adult patients with H. pylori infection and duodenal ulcer disease (active or history of within the past 5 years) to eradicate H. pylori.

In patients who fail therapy, susceptibility testing should be done. If resistance to clarithromycin is demonstrated or susceptibility testing is not possible, alternative antimicrobial therapy should be instituted [see Clinical Pharmacology (12.4) and the prescribing information for clarithromycin].

Esomeprazole magnesium for delayed-release oral suspension is indicated for the long-term treatment of pathological hypersecretory conditions, including Zollinger-Ellison Syndrome, in adults.

Table 1 shows the recommended adult dosage of esomeprazole magnesium for delayed-release oral suspension by indication.

The duration of esomeprazole magnesium treatment should be based on available safety and efficacy data specific to the defined indication and dosing frequency and individual patient medical needs. Esomeprazole magnesium for delayed-release oral suspension should only be initiated and continued if the benefits outweigh the risks of treatment.

<div class="scrollingtable"><table width="655"> <caption> <span> Table 1: Recommended Dosage of Esomeprazole Magnesium for Delayed-Release Oral Suspension in Adults by Indication </span> </caption> <colgroup> <col width="187"/> <col width="264"/> <col width="203"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="3"> <p class="First First Footnote"> <span class="Sup">1. </span>A maximum dosage of 20 mg once daily is recommended for patients with severe liver impairment (Child-Pugh Class C) <span class="Italics">[see <span class="Underline">Use in Specific Populations (8.6)</span>]. </span> </p> </td> </tr> <tr> <td align="left" colspan="3"> <p class="First First Footnote"> <span class="Sup">2.</span> Most patients are healed within 4 to 8 weeks. For patients who do not heal after 4 to 8 weeks, an additional 4 to 8 weeks of treatment may be required to achieve healing <span class="Italics">[see <span class="Underline">Clinical Studies (14.1)</span>]</span> .</p> </td> </tr> <tr> <td align="left" colspan="3"> <p class="First First Footnote"> <span class="Sup">3.</span> Refer to the amoxicillin and clarithromycin prescribing information for dosage adjustments in elderly and renally-impaired patients.</p> </td> </tr> <tr class="Last"> <td align="left" colspan="3"> <p class="First First Footnote"> <span class="Sup">4.</span> A starting dosage of 20 mg twice daily is recommended for patients with severe liver impairment (Child-Pugh Class C) <span class="Italics">[see <span class="Underline">Use in Specific Populations (8.6)</span>]</span> .</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold"> Adult Indication</span></td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Recommended Dosage of Esomeprazole Magnesium for Delayed-Release Oral</span> <br/> <span class="Bold">Suspension</span></td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Treatment Duration</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Healing of EE</td><td align="left" class="Botrule Rrule" valign="top">20 mg or 40 mg<span class="Sup">1  </span>once daily</td><td align="left" class="Botrule Rrule" valign="top">4 to 8 weeks<span class="Sup">2 </span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Maintenance of Healing of EE</td><td align="left" class="Botrule Rrule" valign="top">20 mg once daily</td><td align="left" class="Botrule Rrule" valign="top">Controlled studies do not extend beyond 6 months</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Treatment of Symptomatic GERD</td><td align="left" class="Botrule Rrule" valign="top">20 mg once daily</td><td align="left" class="Botrule Rrule" valign="top">4 weeks; if symptoms do not resolve completely, consider an additional 4 weeks </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Risk Reduction of NSAID-Associated Gastric Ulcer</td><td align="left" class="Botrule Rrule" valign="top">20 mg or 40 mg<span class="Sup">1 </span>once daily</td><td class="Botrule Rrule" valign="top">Controlled studies do not extend beyond 6 months </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Italics">H. pylori </span> Eradication to Reduce the Risk of Duodenal Ulcer Recurrence (Triple Therapy)</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 40 mg once daily<span class="Sup">1 </span> <br/> Amoxicillin 1000 mg twice daily<span class="Sup">3 </span>Clarithromycin 500 mg twice daily<span class="Sup">3 </span></td><td align="left" class="Botrule Rrule" valign="top"> <p class="First">10 days</p> <p></p> <p>10 days <br/> 10 days</p> </td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" valign="top">Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome</td><td align="left" class="Botrule Rrule" valign="top"> <p class="First">Starting dosage is 40 mg twice daily<span class="Sup">4</span>; individualize the regimen to patient needs.</p> <p>Dosages of up to 240 mg/day have been administered <span class="Italics">[see <span class="Underline">Clinical Studies (14.7)</span>].</span> </p> </td><td align="left" class="Botrule Rrule" valign="top">As long as clinically indicated</td> </tr> </tbody> </table></div>

Table 2 shows the recommended dosage of esomeprazole magnesium in pediatric patients by indication.

<div class="scrollingtable"><table width="100%"> <caption> <span>Table 2: Recommended Dosage of Esomeprazole magnesium in Pediatric Patients by Indication</span> </caption> <colgroup> <col width="25%"/> <col width="25%"/> <col width="31%"/> <col width="17%"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">1 </span>Dosages over 1 mg/kg/day have not been studied</p> </td> </tr> <tr class="Last"> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">2 </span>Dosages over 1.33 mg/kg/day have not been studied</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Indication</span></td><td align="left" class="Botrule Rrule Toprule"><span class="Bold"> Patient Age</span></td><td align="left" class="Botrule Rrule Toprule"><span class="Bold"> Recommended Dosage</span></td><td align="left" class="Botrule Rrule Toprule"><span class="Bold"> Duration</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" rowspan="2"> <br/> Healing of EE</td><td align="left" class="Botrule Rrule">12 years to 17 years</td><td align="left" class="Botrule Rrule">Esomeprazole magnesium for delayed-release oral suspension: 20 mg or 40 mg once daily</td><td align="left" class="Botrule Rrule">4 to 8 Weeks</td> </tr> <tr> <td align="left" class="Botrule Rrule"> <br/> 1 year to 11 years<span class="Sup">1</span></td><td align="left" class="Botrule Rrule">Esomeprazole magnesium for delayed-release oral suspension:<br/> <span class="Underline">Less than 20 kg</span> <br/> 10 mg once daily <br/> <span class="Underline">20 kg and greater</span> <br/>10 mg or 20 mg once daily</td><td align="left" class="Botrule Rrule">8 weeks</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule">Treatment of EE due to Acid-Mediated GERD</td><td align="left" class="Botrule Rrule">1 month to less than 1 year<span class="Sup">2</span></td><td align="left" class="Botrule Rrule">Esomeprazole magnesium for delayed-release oral suspension:<br/> <br/> <span class="Underline">3 kg to 5 kg </span> <br/> 2.5 mg once daily <br/> <br/> <span class="Underline">Greater than 5 kg to 7.5 kg </span> <br/> 5 mg once daily <br/> <br/> <span class="Underline">Greater than 7.5 kg to 12 kg </span> <br/> 10 mg once daily</td><td align="left" class="Botrule Rrule">Up to 6 weeks</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" rowspan="2">Treatment of Symptomatic GERD</td><td align="left" class="Botrule Rrule">12 years to 17 years</td><td align="left" class="Botrule Rrule">Esomeprazole magnesium for delayed-release oral suspension:<br/> 20 mg once daily</td><td align="left" class="Botrule Rrule">4 weeks</td> </tr> <tr class="Last"> <td align="left" class="Botrule Rrule">1 year to 11 years</td><td align="left" class="Botrule Rrule">Esomeprazole magnesium for delayed-release oral suspension: 10 mg once daily<span class="Sup">1</span></td><td align="left" class="Botrule Rrule">Up to 8 weeks</td> </tr> </tbody> </table></div>

Esomeprazole Magnesium For Delayed-Release Oral Suspension

Administer esomeprazole magnesium for delayed-release oral suspension orally or via a nasogastric or gastric tube, as described below.

Oral Administration

1.      Empty the contents of a 2.5 mg or 5 mg esomeprazole packet into a container containing 5 mL of water.  For the 20 mg, and 40 mg strengths, the contents of a packet should be emptied into a container containing 15 mL of water. If two packets are needed, mix in a similar way add twice the required amount of water.

2.      Stir the packet contents into the water.

3.      Leave 2 to 3 minutes to thicken.

4.      Stir and drink within 30 minutes.

5.      If any of the contents remain after drinking, add more water, stir, and drink immediately.

Administration via Nasogastric or Gastric Tube

1.      Add 5 mL of water to a catheter-tipped syringe and then add the contents of a 2.5 mg or 5 mg esomeprazole packet. For the 20 mg, and 40 mg packet strengths, add at least 15 mL of water to the catheter-tipped syringe.

2.      Immediately shake the catheter-tipped syringe and leave 2 to 3 minutes to thicken.

3.      Shake the catheter-tipped syringe and inject through the nasogastric or gastric tube, French size 6 or larger, into the stomach within 30 minutes.

4.      Refill the catheter-tipped syringe with an equal amount of water (5 mL or 15 mL).

5.      Shake and flush any remaining contents from the nasogastric or gastric tube into the stomach.

Esomeprazole Magnesium for Delayed-Release Oral Suspension, 2.5 mg, 5 mg, 20 mg or 40 mg – unit dose packets containing a light yellow, free flow granules consisting of off-white to cream esomeprazole pellets and pale yellow inactive granules.

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{ "type": "ul", "children": [ "Esomeprazole magnesium for delayed-release oral suspension is contraindicated in patients with known hypersensitivity to substituted benzimidazoles or to any component of the formulation. Hypersensitivity reactions may include anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute tubulointerstitial nephritis, and urticaria [see Warnings and Precautions (5.2), Adverse Reactions (6.2)] .", "For information about contraindications of amoxicillin and clarithromycin, indicated in combination with esomeprazole magnesium for delayed-release oral suspension for H. pylori eradication to reduce the risk of duodenal ulcer recurrence, refer to the Contraindications section of the respective prescribing information.", "Proton pump inhibitors (PPIs), including esomeprazole magnesium, are contraindicated in patients receiving rilpivirine-containing products [see Drug Interactions (7)].\n" ], "text": "" }

In adults, symptomatic response to therapy with esomeprazole magnesium for delayed-release oral suspension does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI. In older patients, also consider an endoscopy.

Acute tubulointerstitial nephritis (TIN) has been observed in patients taking PPIs and may occur at any point during PPI therapy. Patients may present with varying signs and symptoms from symptomatic hypersensitivity reactions to non-specific symptoms of decreased renal function (e.g., malaise, nausea, anorexia). In reported case series, some patients were diagnosed on biopsy and in the absence of extra-renal manifestations (e.g., fever, rash or arthralgia). Discontinue esomeprazole magnesium for delayed-release oral suspension and evaluate patients with suspected acute TIN [see Contraindications (4)].

Published observational studies suggest that PPI therapy like esomeprazole magnesium for delayed-release oral suspension may be associated with an increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve [see Adverse Reactions (6.2)].

Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents. For more information specific to antibacterial agents (clarithromycin and amoxicillin) indicated for use in combination with esomeprazole magnesium, refer to Warnings and Precautions section of the corresponding prescribing information.

Several published observational studies suggest that proton pump inhibitor (PPI) therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines [see Dosage and Administration (2) and Adverse Reactions (6.2)].

Severe cutaneous adverse reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) have been reported in association with the use of PPIs [see Adverse Reactions (6.2)].

Discontinue esomeprazole magnesium for delayed-release oral suspension at the first signs or symptoms of severe cutaneous adverse reactions or other signs of hypersensitivity and consider further evaluation.

Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE) have been reported in patients taking PPIs, including esomeprazole. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematosus cases were CLE.

The most common form of CLE reported in patients treated with PPIs was subacute CLE (SCLE) and occurred within weeks to years after continuous drug therapy in patients ranging from infants to the elderly. Generally, histological findings were observed without organ involvement.

Systemic lupus erythematosus (SLE) is less commonly reported than CLE in patients receiving PPIs. PPI associated SLE is usually milder than non-drug induced SLE. Onset of SLE typically occurred within days to years after initiating treatment primarily in patients ranging from young adults to the elderly. The majority of patients presented with rash; however, arthralgia and cytopenia were also reported.

Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving esomeprazole magnesium for delayed-release oral suspension, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks. Serological testing (e.g., ANA) may be positive and elevated serological test results may take longer to resolve than clinical manifestations.

Avoid concomitant use of esomeprazole magnesium with clopidogrel. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as esomeprazole, that inhibit CYP2C19 activity. Concomitant use of clopidogrel with 40 mg esomeprazole reduces the pharmacological activity of clopidogrel. When using esomeprazole magnesium consider alternative anti-platelet therapy [see Drug Interactions (7)].

Daily treatment with any acid-suppressing medications over a long period of time (e.g., longer than 3 years) may lead to malabsorption of cyanocobalamin (vitamin B-12) caused by hypo- or achlorhydria. Rare reports of cyanocobalamin deficiency occurring with acid-suppressing therapy have been reported in the literature. This diagnosis should be considered if clinical symptoms consistent with cyanocobalamin deficiency are observed.

Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures.

Hypomagnesemia may lead to hypocalcemia and/or hypokalemia and may exacerbate underlying hypocalcemia in at-risk patients. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI.

For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically [see Adverse Reactions (6.2)].

Consider monitoring magnesium and calcium levels prior to initiation of esomeprazole magnesium for delayed-release oral suspension and periodically while on treatment in patients with a preexisting risk of hypocalcemia (e.g., hypoparathyroidism). Supplement with magnesium and/or calcium, as necessary. If hypocalcemia is refractory to treatment, consider discontinuing the PPI.

Drugs which induce CYP2C19 or CYP3A4 (such as St. John's Wort or rifampin) can substantially decrease esomeprazole concentrations [see Drug Interactions (7)]. Avoid concomitant use of esomeprazole magnesium for delayed-release oral suspension with St. John's Wort or rifampin.

Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors. Healthcare providers should temporarily stop esomeprazole treatment at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g., for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary [see Clinical Pharmacology (12.2)].

Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration a temporary withdrawal of the PPI may be considered in some patients [see Drug Interactions (7)].

PPI use is associated with an increased risk of fundic gland polyps that increases with long-term use, especially beyond one year. Most PPI users who developed fundic gland polyps were asymptomatic and fundic gland polyps were identified incidentally on endoscopy. Use the shortest duration of PPI therapy appropriate to the condition being treated.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adults

The safety of esomeprazole magnesium delayed-release capsules was evaluated in over 15,000 patients (aged 18 to 84 years) in clinical trials worldwide including over 8,500 patients in the United States and over 6,500 patients in Europe and Canada. Over 2,900 patients were treated in long-term studies for up to 6 to 12 months.

The safety in the treatment of healing of EE in adults was assessed in four randomized comparative clinical trials, which included 1,240 patients who received esomeprazole magnesium 20 mg once daily, 2,434 patients on esomeprazole magnesium 40 mg once daily, and 3,008 patients on omeprazole 20 mg once daily. The most frequently occurring adverse reactions (at least 1%) in all three groups were headache (5.5%, 5%, and 3.8%, respectively) and diarrhea (no difference among the three groups). Nausea, flatulence, abdominal pain, constipation, and dry mouth occurred at similar rates among patients taking esomeprazole magnesium or omeprazole.

Less common adverse reactions with an incidence of less than 1% are listed below by body system:

Body as a Whole: abdomen enlarged, allergic reaction, asthenia, back pain, chest pain, substernal chest pain, facial edema, peripheral edema, hot flushes, fatigue, fever, flu-like disorder, generalized edema, leg edema, malaise, pain, rigors;

Cardiovascular: flushing, hypertension, tachycardia;

Endocrine: goiter;

Gastrointestinal: bowel irregularity, constipation aggravated, dyspepsia, dysphagia, dysplasia GI, epigastric pain, eructation, esophageal disorder, frequent stools, gastroenteritis, GI hemorrhage, GI symptoms not otherwise specified, hiccup, melena, mouth disorder, pharynx disorder, rectal disorder, serum gastrin increased, tongue disorder, tongue edema, ulcerative stomatitis, vomiting;

Hearing: earache, tinnitus;

Hematologic: anemia, anemia hypochromic, cervical lymphadenopathy, epistaxis, leukocytosis, leukopenia, thrombocytopenia;

Hepatic: bilirubinemia, hepatic function abnormal, SGOT increased, SGPT increased;

Metabolic/Nutritional: glycosuria, hyperuricemia, hyponatremia, increased alkaline phosphatase, thirst, vitamin B12 deficiency, weight increase, weight decrease;

Musculoskeletal: arthralgia, arthritis aggravated, arthropathy, cramps, fibromyalgia syndrome, hernia, polymyalgia rheumatica;

Nervous System/Psychiatric: anorexia, apathy, appetite increased, confusion, depression aggravated, dizziness, hypertonia, nervousness, hypoesthesia, impotence, insomnia, migraine, migraine aggravated, paresthesia, sleep disorder, somnolence, tremor, vertigo, visual field defect;

Reproductive: dysmenorrhea, menstrual disorder, vaginitis;

Respiratory: asthma aggravated, coughing, dyspnea, larynx edema, pharyngitis, rhinitis, sinusitis;

Skin and Appendages: acne, angioedema, dermatitis, pruritus, pruritus ani, rash, rash erythematous, rash maculo-papular, skin inflammation, sweating increased, urticaria;

Special Senses: otitis media, parosmia, taste loss, taste perversion;

Urogenital: abnormal urine, albuminuria, cystitis, dysuria, fungal infection, hematuria, micturition frequency, moniliasis, genital moniliasis, polyuria;

Visual: conjunctivitis, vision abnormal.

The following potentially clinically significant laboratory changes in clinical trials, irrespective of relationship to esomeprazole magnesium, were reported in 1% or less of patients: increased creatinine, uric acid, total bilirubin, alkaline phosphatase, ALT, AST, hemoglobin, white blood cell count, platelets, serum gastrin, potassium, sodium, thyroxine and thyroid stimulating hormone [see Clinical Pharmacology (12.2)]. Decreases were seen in hemoglobin, white blood cell count, platelets, potassium, sodium, and thyroxine.

Endoscopic findings that were reported as adverse reactions include: duodenitis, esophagitis, esophageal stricture, esophageal ulceration, esophageal varices, gastric ulcer, gastritis, hernia, benign polyps or nodules, Barrett's esophagus, and mucosal discoloration.

The incidence of adverse reactions during 6-month trials for the maintenance of healing of EE with esomeprazole magnesium 20 mg once daily was similar to placebo. There were no differences in types of adverse reactions seen during maintenance treatment up to 12 months compared to short-term treatment.

Two placebo-controlled studies were conducted in 710 adult patients for the treatment of symptomatic GERD. The most common adverse reactions that were reported were: diarrhea (4%), headache (4%), and abdominal pain (4%).

Combination Treatment with Esomeprazole Magnesium, Amoxicillin and Clarithromycin

In clinical trials of H. pylori eradication of to reduce duodenal ulcer recurrence, no additional adverse reactions specific to the combination of esomeprazole magnesium delayed-release capsules, amoxicillin and clarithromycin were observed and were similar to those observed with esomeprazole magnesium, amoxicillin, or clarithromycin alone. The most frequently reported adverse reactions for patients who received esomeprazole magnesium, amoxicillin and clarithromycin for 10 days were diarrhea (9%), taste perversion (4%), and abdominal pain (4%). No adverse reactions were observed at higher rates with esomeprazole magnesium, amoxicillin and clarithromycin than were observed with esomeprazole magnesium alone.

In clinical trials using of esomeprazole magnesium, amoxicillin and clarithromycin, no additional increased laboratory abnormalities particular to these drug combinations were observed.

For more information on adverse reactions and laboratory changes with amoxicillin or clarithromycin, refer to Adverse Reactions section of the respective prescribing information.

Pediatrics

1 Year to 17 Years of Age

The safety of esomeprazole magnesium for delayed-release oral suspension was evaluated in 316 pediatric and adolescent patients aged 1 year to 17 years in four clinical trials for the treatment of symptomatic GERD [see Clinical Studies (14.3)]. In 109 pediatric patients aged 1 year to 11 years, the most frequently reported (at least 1%) treatment-related adverse reactions in these patients were diarrhea (3%), headache (2%) and somnolence (2%). In 149 pediatric patients aged 12 years to 17 years the most frequently reported adverse reactions (at least 2%) were headache (8%), abdominal pain (3%), diarrhea (2%), and nausea (2%).

1 Month to Less Than 1 Year of Age

The safety of esomeprazole magnesium was evaluated in 167 infants from 1 month to less than 1 year of age with GERD in three clinical trials [see Use in Specific Populations (8.4)]. In a study that included 43 pediatric patients, the most frequently reported adverse reactions (at least 5%) with esomeprazole magnesium were irritability and vomiting. In a study that included 98 pediatric patients, administered esomeprazole magnesium for up to 6 weeks (including 39 patients randomized to the withdrawal phase), reported adverse reactions were: abdominal pain (1%), regurgitation (1%), tachypnea (1%), and increased ALT (1%).

The following adverse reactions have been identified during post-approval use of esomeprazole. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reports are listed below by body system:

Blood and Lymphatic: agranulocytosis, pancytopenia;

Eye: blurred vision;

Gastrointestinal: pancreatitis; stomatitis; microscopic colitis; fundic gland polyps;

Hepatobiliary: hepatic failure, hepatitis with or without jaundice;

Immune System: anaphylactic reaction/shock; systemic lupus erythematosus;

Infections and Infestations: GI candidiasis; Clostridium difficile-associated diarrhea;

Metabolism and nutritional disorders: hypomagnesemia (may lead to hypocalcemia and/or hypokalemia) [see Warnings and Precautions (5.9)];

Musculoskeletal and Connective Tissue: muscular weakness, myalgia, bone fracture;

Nervous System: hepatic encephalopathy, taste disturbance;

Psychiatric: aggression, agitation, depression, hallucination;

Renal and Urinary: interstitial nephritis;

Reproductive System and Breast: gynecomastia, erectile dysfunction;

Respiratory, Thoracic, and Mediastinal: bronchospasm;

Skin and Subcutaneous Tissue: alopecia, erythema multiforme, hyperhidrosis, photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis (some fatal), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP), cutaneous lupus erythematosus.

Adverse reactions associated with omeprazole may also be expected to occur with esomeprazole. See the full prescribing information for omeprazole for complete safety information.

Tables 3 and 4 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them.

{ "type": "p", "children": [], "text": "\nTables 3 and 4 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them." }

Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs.

{ "type": "p", "children": [], "text": "Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs." }

<div class="scrollingtable"><table width="100%"> <caption> <span> Table 3: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics </span> </caption> <colgroup> <col width="21%"/> <col width="78%"/> </colgroup> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule" colspan="2" valign="top"><span class="Bold"> Antiretrovirals</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known.<br/> <ul> <li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical </span><span class="Italics">Pharmacology (12.3)</span></span><span class="Italics"><span class="Underline">]</span>.</span> </li> <li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical </span><span class="Italics">Pharmacology (12.3)</span></span><span class="Italics">].</span> </li> <li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole.</li> </ul> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top"><span class="Underline">Rilpivirine-containing products:</span> Concomitant use with esomeprazole magnesium is contraindicated <span class="Italics">[see </span><span class="Underline"><span class="Italics">Contraindications (4)</span></span><span class="Italics"><span class="Underline">]</span></span>.<br/> <span class="Underline">Atazanavir:</span> See prescribing information for atazanavir for dosing information.<br/> <span class="Underline">Nelfinavir:</span> Avoid concomitant use with esomeprazole magnesium. See prescribing information for nelfinavir.<br/> <span class="Underline">Saquinavir:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities.<br/> <span class="Underline">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Warfarin</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> <br/> <span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death.</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"> <p class="First"> <span class="Italics">Intervention:</span> </p> </td><td align="left" class="Botrule Rrule" valign="top">Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Methotrexate</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> <br/> <br/> <span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class="Italics">[see </span><span class="Underline"><span class="Italics">Warnings and Precautions (5.12)</span></span><span class="Italics">].</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">A temporary withdrawal of esomeprazole magnesium may be considered in some patients receiving high-dose methotrexate.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> 2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol)</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Clopidogrel</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> <br/> <br/> <span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical </span><span class="Italics">Pharmacology (12.3)</span></span><span class="Italics"><span class="Underline">]</span></span><span class="Italics">.</span> <br/> There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel<span class="Italics">.</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Avoid concomitant use with esomeprazole magnesium Consider use of alternative anti-platelet therapy <span class="Italics">[see </span><span class="Underline"><span class="Italics">Warnings and Precautions (5.7)</span></span><span class="Italics">].</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Citalopram</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Increased exposure of citalopram leading to an increased risk of QT prolongation <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical Pharmacology (12.3)</span></span><span class="Italics">].</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Cilostazol</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical Pharmacology (12.3)</span></span><span class="Italics">].</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Digoxin</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Potential for increased exposure of digoxin <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical Pharmacology (12.3)</span></span><span class="Italics">].</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Combination Therapy with Clarithromycin and Amoxicillin</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> <br/> <span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Concomitant administration of clarithromycin with other drugs can lead to serious adverse reactions, including potentially fatal arrhythmias, and are contraindicated.<br/> <br/> Amoxicillin also has drug interactions.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> <br/> <span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">See <span class="Italics">Contraindications, Warnings </span> and <span class="Italics">Precautions </span> in prescribing information for clarithromycin.<br/> <br/> See <span class="Italics">Drug Interactions </span> in prescribing information for amoxicillin.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole)</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole magnesium and MMF. Use esomeprazole magnesium with caution in transplant patients receiving MMF <span class="Italics">[</span><span class="Italics">see <span class="Underline">Clinical Pharmacology (12.3)</span></span><span class="Italics"><span class="Underline">]</span></span>.<br/> <br/> See the prescribing information for other drugs dependent on gastric pH for absorption.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Tacrolimus</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class="Italics">.</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Interactions with Investigations of Neuroendocrine Tumors</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class="Italics">[see </span><span class="Underline"><span class="Italics">Warnings and Precautions (5.11), </span><span class="Italics">Clinical </span><span class="Italics">Pharmacology (12.2)</span></span><span class="Italics"><span class="Underline">]</span></span><span class="Italics">.</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Discontinue esomeprazole magnesium at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> Interaction with Secretin Stimulation Test</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma.</td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Discontinue esomeprazole magnesium 4 weeks prior to testing <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical Pharmacology (12.2)</span></span><span class="Italics">]</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"><span class="Bold"> False Positive Urine Tests for THC</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">There have been reports of false positive urine screening test for tetrahydrocannabinol (THC) in patients receiving PPIs.</td> </tr> <tr class="Last"> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">An alternative confirmatory method should be considered to verify positive results.</td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"100%\">\n<caption>\n<span> Table 3: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics </span>\n</caption>\n<colgroup>\n<col width=\"21%\"/>\n<col width=\"78%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td align=\"left\" class=\"Botrule Lrule Rrule Toprule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Antiretrovirals</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known.<br/>\n<ul>\n<li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical </span><span class=\"Italics\">Pharmacology (12.3)</span></span><span class=\"Italics\"><span class=\"Underline\">]</span>.</span>\n</li>\n<li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical </span><span class=\"Italics\">Pharmacology (12.3)</span></span><span class=\"Italics\">].</span>\n</li>\n<li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole.</li>\n</ul>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"><span class=\"Underline\">Rilpivirine-containing products:</span> Concomitant use with esomeprazole magnesium is contraindicated <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Contraindications (4)</span></span><span class=\"Italics\"><span class=\"Underline\">]</span></span>.<br/>\n<span class=\"Underline\">Atazanavir:</span> See prescribing information for atazanavir for dosing information.<br/>\n<span class=\"Underline\">Nelfinavir:</span> Avoid concomitant use with esomeprazole magnesium. See prescribing information for nelfinavir.<br/>\n<span class=\"Underline\">Saquinavir:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities.<br/>\n<span class=\"Underline\">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Warfarin</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\">\n<br/>\n<span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death.</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\">\n<p class=\"First\">\n<span class=\"Italics\">Intervention:</span>\n</p>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Methotrexate</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\">\n<br/>\n<br/>\n<span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Warnings and Precautions (5.12)</span></span><span class=\"Italics\">].</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">A temporary withdrawal of esomeprazole magnesium may be considered in some patients receiving high-dose methotrexate.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> 2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol)</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Clopidogrel</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\">\n<br/>\n<br/>\n<span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical </span><span class=\"Italics\">Pharmacology (12.3)</span></span><span class=\"Italics\"><span class=\"Underline\">]</span></span><span class=\"Italics\">.</span>\n<br/> There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel<span class=\"Italics\">.</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Avoid concomitant use with esomeprazole magnesium Consider use of alternative anti-platelet therapy <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Warnings and Precautions (5.7)</span></span><span class=\"Italics\">].</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Citalopram</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Increased exposure of citalopram leading to an increased risk of QT prolongation <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical Pharmacology (12.3)</span></span><span class=\"Italics\">].</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Cilostazol</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical Pharmacology (12.3)</span></span><span class=\"Italics\">].</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Digoxin</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Potential for increased exposure of digoxin <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical Pharmacology (12.3)</span></span><span class=\"Italics\">].</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Combination Therapy with Clarithromycin and Amoxicillin</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\">\n<br/>\n<span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Concomitant administration of clarithromycin with other drugs can lead to serious adverse reactions, including potentially fatal arrhythmias, and are contraindicated.<br/>\n<br/> Amoxicillin also has drug interactions.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\">\n<br/>\n<span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">See <span class=\"Italics\">Contraindications, Warnings </span> and <span class=\"Italics\">Precautions </span> in prescribing information for clarithromycin.<br/>\n<br/> See <span class=\"Italics\">Drug Interactions </span> in prescribing information for amoxicillin.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole)</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole magnesium and MMF. Use esomeprazole magnesium with caution in transplant patients receiving MMF <span class=\"Italics\">[</span><span class=\"Italics\">see <span class=\"Underline\">Clinical Pharmacology (12.3)</span></span><span class=\"Italics\"><span class=\"Underline\">]</span></span>.<br/>\n<br/> See the prescribing information for other drugs dependent on gastric pH for absorption.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Tacrolimus</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class=\"Italics\">.</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Interactions with Investigations of Neuroendocrine Tumors</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Warnings and Precautions (5.11), </span><span class=\"Italics\">Clinical </span><span class=\"Italics\">Pharmacology (12.2)</span></span><span class=\"Italics\"><span class=\"Underline\">]</span></span><span class=\"Italics\">.</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Discontinue esomeprazole magnesium at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Interaction with Secretin Stimulation Test</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma.</td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Discontinue esomeprazole magnesium 4 weeks prior to testing <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical Pharmacology (12.2)</span></span><span class=\"Italics\">]</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> False Positive Urine Tests for THC</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">There have been reports of false positive urine screening test for tetrahydrocannabinol (THC) in patients receiving PPIs.</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">An alternative confirmatory method should be considered to verify positive results.</td>\n</tr>\n</tbody>\n</table></div>" }

<div class="scrollingtable"><table width="100%"> <caption> <span> Table 4: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs </span> </caption> <colgroup> <col width="21%"/> <col width="78%"/> </colgroup> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule" colspan="2" valign="top"><span class="Bold"> CYP2C19 or CYP3A4 Inducers</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical Pharmacology (12.3)</span></span><span class="Italics"><span class="Underline">]</span>.</span></td> </tr> <tr> <td align="left" valign="top"> <br/> <span class="Italics">Intervention:</span></td><td align="left" valign="top"><span class="Underline">St. John's Wort, rifampin: </span> Avoid concomitant use with <span class="Italics">[see </span><span class="Underline"><span class="Italics">Warnings and Precautions</span><span class="Italics">(5.10)</span></span><span class="Italics">].</span> <br/> Ritonavir-containing products: see prescribing information for specific drugs</td> </tr> <tr> <td align="left" colspan="2" valign="top"><span class="Bold"> Voriconazole</span></td> </tr> <tr> <td align="right" class="Botrule Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span></td><td align="left" class="Botrule Rrule" valign="top">Increased exposure of esomeprazole <span class="Italics">[see </span><span class="Underline"><span class="Italics">Clinical Pharmacology (12.3)</span></span><span class="Italics">].</span></td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" valign="top"> <br/> <br/> <span class="Italics">Intervention:</span></td><td align="left" class="Botrule Rrule" valign="top">Dose adjustment of esomeprazole magnesium is not normally required. However, in patients with Zollinger-Ellison syndrome, who may require higher doses, dosage adjustment may be considered.<br/> See prescribing information for voriconazole.</td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"100%\">\n<caption>\n<span> Table 4: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs </span>\n</caption>\n<colgroup>\n<col width=\"21%\"/>\n<col width=\"78%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td align=\"left\" class=\"Botrule Lrule Rrule Toprule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> CYP2C19 or CYP3A4 Inducers</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical Pharmacology (12.3)</span></span><span class=\"Italics\"><span class=\"Underline\">]</span>.</span></td>\n</tr>\n<tr>\n<td align=\"left\" valign=\"top\">\n<br/>\n<span class=\"Italics\">Intervention:</span></td><td align=\"left\" valign=\"top\"><span class=\"Underline\">St. John's Wort, rifampin: </span> Avoid concomitant use with <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Warnings and Precautions</span><span class=\"Italics\">(5.10)</span></span><span class=\"Italics\">].</span>\n<br/> Ritonavir-containing products: see prescribing information for specific drugs</td>\n</tr>\n<tr>\n<td align=\"left\" colspan=\"2\" valign=\"top\"><span class=\"Bold\"> Voriconazole</span></td>\n</tr>\n<tr>\n<td align=\"right\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Increased exposure of esomeprazole <span class=\"Italics\">[see </span><span class=\"Underline\"><span class=\"Italics\">Clinical Pharmacology (12.3)</span></span><span class=\"Italics\">].</span></td>\n</tr>\n<tr class=\"Last\">\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\">\n<br/>\n<br/>\n<span class=\"Italics\">Intervention:</span></td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\">Dose adjustment of esomeprazole magnesium is not normally required. However, in patients with Zollinger-Ellison syndrome, who may require higher doses, dosage adjustment may be considered.<br/> See prescribing information for voriconazole.</td>\n</tr>\n</tbody>\n</table></div>" }

Risk Summary

There are no adequate and well-controlled studies with esomeprazole in pregnant women. Esomeprazole is the S-isomer of omeprazole. Available epidemiologic data fail to demonstrate an increased risk of major congenital malformations or other adverse pregnancy outcomes with first trimester omeprazole use (see Data). Reproduction studies in rats and rabbits resulted in dose-dependent embryo-lethality at omeprazole doses that were approximately 3.4 to 34 times an oral human dose of 40 mg (based on a body surface area for a 60 kg person).

Teratogenicity was not observed in animal reproduction studies with administration of oral esomeprazole magnesium in rats and rabbits with doses about 68 times and 42 times, respectively, an oral human dose of 40 mg (based on a body surface area basis for a 60 kg person). Changes in bone morphology were observed in offspring of rats dosed through most of pregnancy and lactation at doses equal to or greater than approximately 34 times an oral human dose of 40 mg. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age (see Data).

The estimated background risks of major birth defects and miscarriage for the indicated population are unknown. All pregnancies have a background risk of birth defect, loss or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

Data

Human Data

Esomeprazole is the S-isomer of omeprazole. Four epidemiological studies compared the frequency of congenital abnormalities among infants born to women who used omeprazole during pregnancy with the frequency of abnormalities among infants of women exposed to H2-receptor antagonists or other controls.

A population-based retrospective cohort epidemiological study from the Swedish Medical Birth Registry, covering approximately 99% of pregnancies, from 1995 to 1999, reported on 955 infants (824 exposed during the first trimester with 39 of these exposed beyond first trimester, and 131 exposed after the first trimester) whose mothers used omeprazole during pregnancy. The number of infants exposed in utero to omeprazole that had any malformation, low birth weight, low Apgar score, or hospitalization was similar to the number observed in this population. The number of infants born with ventricular septal defects and the number of stillborn infants was slightly higher in the omeprazole-exposed infants than the expected number in this population.

A population-based retrospective cohort study covering all live births in Denmark from 1996 to 2009, reported on 1,800 live births whose mothers used omeprazole during the first trimester of pregnancy and 837,317 live births whose mothers did not use any proton pump inhibitor. The overall rate of birth defects in infants born to mothers with first trimester exposure to omeprazole was 2.9% and 2.6% in infants born to mothers not exposed to any proton pump inhibitor during the first trimester.

A retrospective cohort study reported on 689 pregnant women exposed to either H2-blockers or omeprazole in the first trimester (134 exposed to omeprazole) and 1,572 pregnant women unexposed to either during the first trimester. The overall malformation rate in offspring born to mothers with first trimester exposure to omeprazole, an H2-blocker, or were unexposed was 3.6%, 5.5%, and 4.1% respectively.

A small prospective observational cohort study followed 113 women exposed to omeprazole during pregnancy (89% with first trimester exposures). The reported rate of major congenital malformations was 4% in the omeprazole group, 2% in controls exposed to non-teratogens, and 2.8% in disease paired controls. Rates of spontaneous and elective abortions, preterm deliveries, gestational age at delivery, and mean birth weight were similar among the groups.

Several studies have reported no apparent adverse short-term effects on the infant when single dose oral or intravenous omeprazole was administered to over 200 pregnant women as premedication for cesarean section under general anesthesia.

Animal Data

Omeprazole

Reproductive studies conducted with omeprazole in rats at oral doses up to 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at doses up to 69.1 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) during organogenesis did not disclose any evidence for a teratogenic potential of omeprazole. In rabbits, omeprazole in a dose range of 6.9 to 69.1 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis produced dose-related increases in embryo-lethality, fetal resorptions, and pregnancy disruptions. In rats, dose-related embryo/fetal toxicity and postnatal developmental toxicity were observed in offspring resulting from parents treated with omeprazole at 13.8 to 138.0 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis), administered prior to mating through the lactation period.

Esomeprazole

No effects on embryo-fetal development were observed in reproduction studies with esomeprazole magnesium in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) or in rabbits at oral doses up to 86 mg/kg/day (about 41 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis.

A pre- and postnatal developmental toxicity study in rats with additional endpoints to evaluate bone development was performed with esomeprazole magnesium at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). Neonatal/early postnatal (birth to weaning) survival was decreased at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). Body weight and body weight gain were reduced and neurobehavioral or general developmental delays in the immediate post-weaning timeframe were evident at doses equal to or greater than 69 mg/kg/day (about 17 times an oral human dose of 40 mg on a body surface area basis). In addition, decreased femur length, width and thickness of cortical bone, decreased thickness of the tibial growth plate and minimal to mild bone marrow hypocellularity were noted at doses equal to or greater than 14 mg/kg/day (about 3.4 times an oral human dose of 40 mg on a body surface area basis). Physeal dysplasia in the femur was observed in offspring of rats treated with oral doses of esomeprazole magnesium at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis).

Effects on maternal bone were observed in pregnant and lactating rats in a pre- and postnatal toxicity study when esomeprazole magnesium was administered at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). When rats were dosed from gestational day 7 through weaning on postnatal day 21, a statistically significant decrease in maternal femur weight of up to 14% (as compared to placebo treatment) was observed at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis).

A pre- and postnatal development study in rats with esomeprazole strontium (using equimolar doses compared to esomeprazole magnesium study) produced similar results in dams and pups as described above.

A follow up developmental toxicity study in rats with further time points to evaluate pup bone development from postnatal day 2 to adulthood was performed with esomeprazole magnesium at oral doses of 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) where esomeprazole administration was from either gestational day 7 or gestational day 16 until parturition. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age.

Risk Summary

Esomeprazole is the S-isomer of omeprazole and limited data suggest that omeprazole may be present in human milk. There are no clinical data on the effects of esomeprazole on the breastfed infant or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for esomeprazole magnesium for delayed-release oral suspension and any potential adverse effects on the breastfed infant from esomeprazole magnesium for delayed-release oral suspension or from the underlying maternal condition.

Healing of EE

Pediatric Patients 1 Year to 17 Years of Age

The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 12 years to 17 years for short-term treatment (4 to 8 weeks) for healing of EE. The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 1 year to 11 years for short-term treatment (up to 8 weeks) for healing of EE. Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety and pharmacokinetic data in pediatric patients 1 year to 17 years of age. The safety profile in pediatric patients 1 year to 17 years of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.4)].

Pediatric Patients 1 Month to Less Than 1 Year of Age

The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 1 month to less than 1 year of age for short-term treatment (up to 6 weeks) of EE due to acid-mediated GERD. Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety, pharmacokinetic, and pharmacodynamic data in pediatric patients 1 month to less than 1 year of age. The safety profile in pediatric patients 1 month to less than 1 year of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.2, 12.3)].

The safety and effectiveness of esomeprazole magnesium for the treatment of EE due to acid- mediated GERD in pediatric patients less than 1 month of age have not been established.

Symptomatic GERD

Pediatric Patients 1 Year to 17 Years of Age

The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 12 years to 17 years of age for the short-term treatment (4 weeks) of heartburn and other symptoms associated with GERD. The safety and effectiveness of esomeprazole magnesium for delayed-release oral suspension have been established in pediatric patients 1 year to 11 years of age for the short-term treatment (up to 8 weeks) of heartburn and other symptoms associated with GERD. Use of esomeprazole magnesium for this indication is supported by evidence from adequate and well-controlled studies in adults with additional safety and pharmacokinetic data in pediatric patients 1 year to 17 years of age. The safety profile in pediatric patients 1 year to 17 years of age was similar to adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.4)].

The safety and effectiveness of esomeprazole magnesium for the treatment of symptomatic GERD in pediatric patients less than 1 year of age have not been established.

Infants 1 Month to Less Than 1 Year of Age

Esomeprazole magnesium was not found to be effective in a multicenter, randomized, double-blind, controlled, treatment-withdrawal study of 98 infants aged 1 month to 11 months for the treatment of symptomatic GERD. Patients were enrolled if they had either a clinical diagnosis of suspected GERD, symptomatic GERD, or endoscopically proven GERD. Twenty of 98 enrolled patients underwent endoscopy, and 6 patients were found to have EE on endoscopy at baseline. All patients received esomeprazole magnesium for delayed-release oral suspension once daily during a two-week, open-label phase of the study. There were 80 patients who attained a pre-specified level of symptom improvement and who entered the double-blind phase, in which they were randomized in equal proportions to receive esomeprazole magnesium or placebo for the next four weeks. Efficacy was assessed by observing the time from randomization to study discontinuation due to symptom worsening during the four-week, treatment-withdrawal phase. There was no statistically significant difference between esomeprazole magnesium and placebo in the rate of discontinuation due to symptom worsening; therefore, these results do not support the use of esomeprazole magnesium for the treatment of symptomatic GERD in infants 1 month to less than 1 year of age.

Other Conditions

The safety and effectiveness of esomeprazole magnesium for the risk reduction of NSAID-associated gastric ulcer, H. pylori eradication to reduce the risk of duodenal ulcer recurrence and treatment of pathological hypersecretory conditions have not been established in pediatric patients.

Juvenile Animal Toxicity Studies

In a juvenile rat toxicity study, esomeprazole was administered with both magnesium and strontium salts at oral doses about 34 to 68 times a daily human dose of 40 mg based on body surface area. Increases in death were seen at the high dose, and at all doses of esomeprazole, there were decreases in body weight, body weight gain, femur weight and femur length, and decreases in overall growth [see Nonclinical Toxicology (13.2)].

Of the total number of patients who received esomeprazole magnesium in clinical trials, 1,459 were 65 to 74 years of age and 354 patients were 75 years of age and older.

No overall differences in safety and efficacy were observed between the elderly and younger individuals, and other reported clinical experience has not identified differences in responses between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

In patients with severe hepatic impairment (Child-Pugh Class C) exposure to esomeprazole substantially increased compared to healthy subjects. Dosage modification of esomeprazole magnesium is recommended for patients with severe hepatic impairment for the healing of EE, risk reduction of NSAID-associated gastric ulcer, H. pylori eradication to reduce the risk of duodenal ulcer recurrence, and pathological hypersecretory conditions including Zollinger-Ellison Syndrome [see Dosage and Administration (2.1), Clinical Pharmacology (12.3)].

In patients with mild to moderate liver impairment (Child-Pugh Classes A and B), no dosage adjustment is necessary.

Manifestations in patients exposed to omeprazole, the racemic mixture, at doses up to 2,400 mg (120 times the usual recommended clinical dose) include confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive.

{ "type": "p", "children": [], "text": "\nManifestations in patients exposed to omeprazole, the racemic mixture, at doses up to 2,400 mg (120 times the usual recommended clinical dose) include confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive." }

If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage.

{ "type": "p", "children": [], "text": "If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage." }

The active ingredient in esomeprazole magnesium for delayed-release oral suspension is bis(5-methoxy-2-[(S)-[(4-methoxy-3,5-dimethyl-2-pyridinyl)methyl]sulfinyl]-1H-benzimidazole-1-yl) magnesium, a PPI. Esomeprazole is the S-isomer of omeprazole, which is a mixture of the S- and R- isomers. (Initial U.S. approval of esomeprazole magnesium: 2001). Its molecular formula is (C17H18N3O3S)2Mg with molecular weight of 713.1 on an anhydrous basis. The structural formula is:

{ "type": "p", "children": [], "text": "\nThe active ingredient in esomeprazole magnesium for delayed-release oral suspension is bis(5-methoxy-2-[(S)-[(4-methoxy-3,5-dimethyl-2-pyridinyl)methyl]sulfinyl]-1H-benzimidazole-1-yl) magnesium, a PPI. Esomeprazole is the S-isomer of omeprazole, which is a mixture of the S- and R- isomers. (Initial U.S. approval of esomeprazole magnesium: 2001). Its molecular formula is (C17H18N3O3S)2Mg with molecular weight of 713.1 on an anhydrous basis. The structural formula is:" }

The magnesium salt is a white to slightly colored crystalline powder. The stability of esomeprazole magnesium USP is a function of pH; it rapidly degrades in acidic media, but it has acceptable stability under alkaline conditions. At pH 6.8 (buffer), the half-life of the magnesium salt is about 19 hours at 25°C and about 8 hours at 37°C.

{ "type": "p", "children": [], "text": "\nThe magnesium salt is a white to slightly colored crystalline powder. The stability of esomeprazole magnesium USP is a function of pH; it rapidly degrades in acidic media, but it has acceptable stability under alkaline conditions. At pH 6.8 (buffer), the half-life of the magnesium salt is about 19 hours at 25°C and about 8 hours at 37°C.\n" }

Esomeprazole magnesium for delayed-release oral suspension is supplied in packets. Each packet of Esomeprazole magnesium for delayed-release oral suspension contains esomeprazole magnesium USP equivalent to esomeprazole 2.5 mg, 5 mg, 20 mg, or 40 mg, in the form of enteric-coated pellets.

{ "type": "p", "children": [], "text": "Esomeprazole magnesium for delayed-release oral suspension is supplied in packets. Each packet of Esomeprazole magnesium for delayed-release oral suspension contains esomeprazole magnesium USP equivalent to esomeprazole 2.5 mg, 5 mg, 20 mg, or 40 mg, in the form of enteric-coated pellets." }

Each packet of esomeprazole magnesium for delayed-release oral suspension contains esomeprazole, in the form of enteric-coated pellets, and also inactive granules:

{ "type": "p", "children": [], "text": "Each packet of esomeprazole magnesium for delayed-release oral suspension contains esomeprazole, in the form of enteric-coated pellets, and also inactive granules:" }

{ "type": "ul", "children": [ "2.5 mg esomeprazole (equivalent to 2.588 mg esomeprazole magnesium USP)", "5 mg esomeprazole (equivalent to 5.176 mg esomeprazole magnesium USP)", "20 mg esomeprazole (equivalent to 20.706 mg esomeprazole magnesium USP)", "40 mg esomeprazole (equivalent to 41.411 mg esomeprazole magnesium USP)" ], "text": "" }

The inactive granules are composed of the following ingredients: citric acid monohydrate, colloidal silicon dioxide, crospovidone, dextrose monohydrate, ferric oxide yellow, hydroxy propyl cellulose and xanthan gum. Esomeprazole 2.5 mg, 5 mg, 20 mg, and 40 mg pellets contains following ingredients: ethyl cellulose, magnesium oxide (light), magnesium stearate, methacrylic acid and ethyl acrylate copolymer dispersion, mono and diglycerides, polysorbate 80, povidone, sugar spheres 60-80 mesh, talc and triethyl citrate. The esomeprazole pellets and inactive granules are constituted with water to form a suspension and are given by oral, nasogastric, or gastric administration.

{ "type": "p", "children": [], "text": "The inactive granules are composed of the following ingredients: citric acid monohydrate, colloidal silicon dioxide, crospovidone, dextrose monohydrate, ferric oxide yellow, hydroxy propyl cellulose and xanthan gum. Esomeprazole 2.5 mg, 5 mg, 20 mg, and 40 mg pellets contains following ingredients: ethyl cellulose, magnesium oxide (light), magnesium stearate, methacrylic acid and ethyl acrylate copolymer dispersion, mono and diglycerides, polysorbate 80, povidone, sugar spheres 60-80 mesh, talc and triethyl citrate. The esomeprazole pellets and inactive granules are constituted with water to form a suspension and are given by oral, nasogastric, or gastric administration." }

Esomeprazole belongs to a class of antisecretory compounds, the substituted benzimidazoles, that suppress gastric acid secretion by specific inhibition of the H+/K+ ATPase enzyme system at the secretory surface of the gastric parietal cell. Esomeprazole is protonated and converted in the acidic compartment of the parietal cell forming the active inhibitor, the achiral sulphenamide. Because this enzyme system is regarded as the acid (proton) pump within the gastric mucosa, esomeprazole has been characterized as a gastric acid-pump inhibitor, in that it blocks the final step of acid production. This effect is dose-related and leads to inhibition of both basal and stimulated acid secretion irrespective of the stimulus.

Antisecretory Activity

Adults

The effect of esomeprazole on intragastric pH was determined in adult patients with symptomatic GERD in two separate studies. In the first study of 36 patients, esomeprazole magnesium 40 mg and 20 mg delayed-release capsules were administered once daily over 5 days as  shown in Table 5:

<div class="scrollingtable"><table width="100%"> <caption> <span> Table 5: Effect of Esomeprazole on Intragastric pH on Day 5 (N=36) Following Once Daily Dosing of Esomeprazole Magnesium Delayed-Release Capsules in Adult Patients with Symptomatic GERD </span> </caption> <colgroup> <col width="44%"/> <col width="27%"/> <col width="27%"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="3"> <p class="First First Footnote"> <span class="Sup">1.</span>Gastric pH was measured over a 24-hour period</p> </td> </tr> <tr class="Last"> <td align="left" colspan="3"> <p class="First First Footnote"> <span class="Sup">2. </span>p&lt; 0.01 esomeprazole magnesium 40 mg vs. esomeprazole magnesium 20 mg</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top">Parameter</td><td align="left" class="Botrule Rrule Toprule" colspan="2" valign="top">Esomeprazole Magnesium Delayed-Release Capsules</td> </tr> <tr> <td class="Botrule Lrule Rrule" valign="top"></td><td align="left" class="Botrule Rrule" valign="top">40 mg once daily</td><td align="left" class="Botrule Rrule" valign="top">20 mg once daily</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">% Time Gastric pH &gt;4<span class="Italics"><span class="Sup">1</span></span> (Hours)</td><td align="left" class="Botrule Rrule" valign="top">70%<span class="Italics"><span class="Sup">2</span></span> <br/> (16.8 h)</td><td align="left" class="Botrule Rrule" valign="top">53%<br/> (12.7 h)</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Coefficient of variation</td><td align="left" class="Botrule Rrule" valign="top">26%</td><td align="left" class="Botrule Rrule" valign="top">37%</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Median 24 Hour pH</td><td align="left" class="Botrule Rrule">4.9<span class="Italics"><span class="Sup">2</span></span></td><td align="left" class="Botrule Rrule">4.1</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" valign="top">Coefficient of variation</td><td align="left" class="Botrule Rrule" valign="top">16%</td><td align="left" class="Botrule Rrule" valign="top">27%</td> </tr> </tbody> </table></div>

In a second study, the effect on intragastric pH of esomeprazole magnesium 40 mg delayed-release capsules administered once daily over a five-day period was similar to the first study, (% time with pH > 4 was 68% or 16.3 hours).

Pediatrics

In infants (1 to 11 months old, inclusive) with GERD given esomeprazole magnesium for delayed-release oral suspension 1 mg/kg once daily, the percent time with intragastric pH > 4 increased from 29% at baseline to 69% on Day 7, which is similar to the pharmacodynamic effect in adults.

Serum Gastrin Effects

The effect of esomeprazole on serum gastrin concentrations was evaluated in approximately 2,700 patients in clinical trials of oral esomeprazole for up to 8 weeks and in over 1,300 patients for up to 12 months. The mean fasting gastrin level increased in a dose-related manner. The increase in serum gastrin concentrations reached a plateau within two to three months of therapy and returned to baseline levels within four weeks after discontinuation of therapy.

Increased gastrin causes enterochromaffin-like cell hyperplasia and increased serum Chromogranin A (CgA) levels. The increased CgA levels may cause false positive results in diagnostic investigations for neuroendocrine tumors [see Warnings and Precautions (5.11)]

Enterochromaffin-like (ECL) Cell Effects

Human gastric biopsy specimens have been obtained from more than 3,000 patients (both pediatrics and adults) treated with omeprazole in long-term clinical trials. The incidence of ECL cell hyperplasia in these studies increased with time; however, no case of ECL cell carcinoids, dysplasia, or neoplasia has been found in these patients [see Nonclinical Toxicology (13.1)]

In over 1,000 patients treated with oral esomeprazole (10 mg, 20 mg or 40 mg/day) for up to 12 months, the prevalence of ECL cell hyperplasia increased with time and dose. No patient developed ECL cell carcinoids, dysplasia, or neoplasia in the gastric mucosa.

Endocrine Effects

Esomeprazole had no effect on thyroid function in adults when given esomeprazole magnesium 20 mg or 40 mg delayed-release capsules once daily for 4 weeks. Other effects of esomeprazole on the endocrine system were assessed in studies of omeprazole. Oral doses of omeprazole 30 mg or 40 mg once daily for 2 to 4 weeks had no effect on carbohydrate metabolism, circulating levels of parathyroid hormone, cortisol, estradiol, testosterone, prolactin, cholecystokinin, or secretin.

Absorption

Esomeprazole magnesium for delayed-release oral suspension showed similar bioavailability after a single dose (40 mg) administration in 94 healthy male and female subjects under fasting conditions. After oral administration, peak plasma levels (Cmax) of esomeprazole occur at approximately 1.5 hours (Tmax). The Cmax increases proportionally when the dose is increased, and there is a three-fold increase in the area under the plasma concentration-time curve (AUC) from 20 to 40 mg. At repeated once-daily dosing with 40 mg, the systemic bioavailability is approximately 90% compared to 64% after a single dose of 40 mg. The mean exposure (AUC) to esomeprazole increases from 4.32 micromol*hr/L on Day 1 to 11.2 micromol*hr/L on Day 5 after 40 mg once daily dosing.

The AUC after administration of a single 40 mg dose of esomeprazole magnesium delayed-release capsules is decreased by 43% to 53% after food intake compared to fasting conditions [see Dosage and Administration (2.3)]. The pharmacokinetics of esomeprazole in adult patients with symptomatic GERD following repeated once daily administration of 20 mg and 40 mg esomeprazole magnesium delayed-release capsules over a period of five days are shown in Table 6:

<div class="scrollingtable"><table width="100%"> <caption> <span> Table 6: Geometric Mean (95% CI) Pharmacokinetic Parameters of Esomeprazole on Day 5 Following Once Daily Dosing of Esomeprazole Magnesium Delayed-Release Capsules in Adult Patients with Symptomatic GERD </span> </caption> <colgroup> <col width="47%"/> <col width="20%"/> <col width="31%"/> </colgroup> <tfoot> <tr class="First First Last Last"> <td align="left" colspan="3"> <p class="First First Footnote"> <span class="Sup">1. </span>Values represent the geometric mean, except the T<span class="Sub">max</span>, which is the arithmetic mean; CV = Coefficient of variation</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td class="Botrule Lrule Rrule Toprule" valign="top"></td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"><span class="Bold"> Esomeprazole Magnesium delayed-release capsules</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> Parameter<span class="Italics"><span class="Sup">1</span></span>(CV)</span></td><td align="left" class="Botrule Rrule" valign="top"><span class="Bold"> 40 mg once daily (n=36)</span></td><td align="left" class="Botrule Rrule" valign="top"><span class="Bold"> 20 mg once daily (n=36)</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">AUC (micromol∙h/L)</td><td align="left" class="Botrule Rrule" valign="top">12.6 (42%)</td><td align="left" class="Botrule Rrule" valign="top">4.2 (59%)</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">C<span class="Sub">max </span>(micromol/L)</td><td align="left" class="Botrule Rrule">4.7 (37%)</td><td align="left" class="Botrule Rrule">2.1 (45%)</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">T<span class="Sub">max </span>(hours)</td><td align="left" class="Botrule Rrule" valign="top">1.6</td><td align="left" class="Botrule Rrule" valign="top">1.6</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" valign="top">t<span class="Sub">1/2 </span>(hours)</td><td align="left" class="Botrule Rrule" valign="top">1.5</td><td align="left" class="Botrule Rrule" valign="top">1.2</td> </tr> </tbody> </table></div>

Esomeprazole is a time-dependent inhibitor of CYP2C19, resulting in autoinhibition and nonlinear pharmacokinetics. The systemic exposure increases in a more than dose proportional manner after multiple oral doses of esomeprazole.

Compared to the first dose, the systemic exposure (Cmax and AUC0-24h) at steady state following once a day dosing increased by 43% and 90%, respectively, compared to after the first dose for the 20 mg dose and increased by 95% and 159%, respectively, for the 40 mg dose.

Distribution

Esomeprazole is 97% bound to plasma proteins. Plasma protein binding is constant over the concentration range of 2 to 20 micromol/L. The apparent volume of distribution at steady state in healthy subjects is approximately 16 L.

Elimination

Metabolism

Esomeprazole is extensively metabolized in the liver by the cytochrome P450 (CYP) enzyme system. The metabolites of esomeprazole lack antisecretory activity. The major part of esomeprazole's metabolism is dependent upon the CYP2C19 isoenzyme, which forms the hydroxy and desmethyl metabolites. The remaining amount is dependent on CYP3A4 which forms the sulphone metabolite.

Excretion

The plasma elimination half-life of esomeprazole is approximately 1 to 1.5 hours. Less than 1% of parent drug is excreted in the urine. Approximately 80% of an oral dose of esomeprazole is excreted as inactive metabolites in the urine, and the remainder is found as inactive metabolites in the feces.

Combination Therapy with Amoxicillin and Clarithromycin

Esomeprazole magnesium delayed-release capsules 40 mg once daily was given in combination with amoxicillin 1,000 mg twice daily and clarithromycin 500 mg twice daily for 7 days to 17 healthy male and female subjects. The mean steady state AUC and Cmax of esomeprazole increased by 70% and 18%, respectively during combination therapy compared to treatment with esomeprazole magnesium alone. The observed increase in esomeprazole exposure during co-administration with amoxicillin and clarithromycin is not expected to be clinically relevant.

The pharmacokinetic parameters for amoxicillin and clarithromycin were similar during combination therapy and administration of each drug alone. However, the mean AUC and Cmax for 14-hydroxyclarithromycin increased by 19% and 22%, respectively, during combination therapy compared to treatment with clarithromycin alone. This increase in exposure to 14-hydroxyclarithromycin is not considered to be clinically relevant.

Specific Populations

Geriatric Patients

The AUC and Cmax values of esomeprazole were slightly higher (25% and 18%, respectively) in the elderly as compared to younger subjects at steady state. This increase in exposure is not considered clinically relevant.

Pediatric Patients

1 Month to 11 Months of Age

The pharmacokinetic parameters following repeated dose administration of esomeprazole magnesium 1 mg/kg once daily for 7 to 8 days in 1 month to 11-month-old infants with GERD are summarized in Table 7.

<div class="scrollingtable"><table width="585px"> <caption> <span> Table 7: Summary of Esomeprazole Pharmacokinetic Parameters Following Once Daily Dosing of Oral Esomeprazole Magnesium for 7 to 8 Days in 1 Month to 1 Year Old Infants with GERD</span> </caption> <colgroup> <col width="254"/> <col width="331"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="2"> <p class="First First Footnote"> <span class="Italics"><span class="Sup">1.</span></span>  Geometric mean</p> </td> </tr> <tr class="Last"> <td align="left" colspan="2"> <p class="First First Footnote"> <span class="Italics"><span class="Sup">2.</span></span>  Median</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold"> Parameter</span></td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Esomeprazole Magnesium 1 mg/kg Orally Once Daily</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">AUC (micromol·h/L) (n=7)<span class="Sup">1</span></td><td align="left" class="Botrule Rrule" valign="top">3.51</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Css,max (micromol/L) (n=15)<span class="Sup">1</span></td><td align="left" class="Botrule Rrule" valign="top">0.87</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">t½ (h) (n=8)<span class="Sup">1</span></td><td align="left" class="Botrule Rrule" valign="top">0.93</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" valign="top">t<span class="Sub">max</span> (h) (n=15)<span class="Sup">2</span></td><td align="left" class="Botrule Rrule" valign="top">3.0</td> </tr> </tbody> </table></div>

Subsequent pharmacokinetic simulation analyses showed that for pediatric patients 1 month to 11 months of age, a dosage regimen of 2.5 mg once daily (body weight 3 to 5 kg), 5 mg once daily (body weight more than 5 to 7.5 kg) and 10 mg once daily for (body weight more than 7.5 to 12 kg)  would achieve comparable steady-state plasma exposures (AUC) to that observed with 10 mg once daily in patients 1 year to 11 year of age and 20 mg once daily in patients 12 years to 18 years of age, as well as adults.

Apparent clearance (CL/F) increases with age in pediatric patients with GERD from 1 month to 2 years of age.

1 Year to 11 Years of Age

The pharmacokinetics of esomeprazole were studied in pediatric patients with GERD aged 1 year to 11 years. Following once daily dosing with esomeprazole magnesium for delayed-release oral suspension for 5 days, the total exposure (AUC) for the 10 mg dosage in patients aged 6 years to 11 years was similar to that seen with the 20 mg dosage in adults and adolescents aged 12 years to 17 years. The total exposure for the 10 mg dosage in patients aged 1 year to 5 years was approximately 30% higher than the 10 mg dosage in patients aged 6 years to 11 years. The total exposure for the 20 mg dosage in patients aged 6 years to 11 years was higher than that observed with the 20 mg dosage in patients aged 12 years to 17 years and adults, but lower than that observed with the 40 mg dosage in 12 to 17 year-olds and adults. See Table 8.

<div class="scrollingtable"><table width="100%"> <caption> <span> Table 8: Summary of Esomeprazole Pharmacokinetic Parameters Following Once Daily Dosing of Esomeprazole Magnesium for Delayed-Release Oral Suspension for 5 Days in 1 Year to 11 Year Old Patients with GERD </span> </caption> <colgroup> <col width="37%"/> <col width="27%"/> <col width="16%"/> <col width="18%"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">1. </span>Geometric mean</p> </td> </tr> <tr class="Last"> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">2. </span>Arithmetic mean</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="center" class="Botrule Lrule Rrule Toprule" rowspan="3"><span class="Bold"> Parameter</span></td><td align="left" class="Botrule Rrule Toprule" colspan="3" valign="top"><span class="Bold"> Esomeprazole Magnesium For Delayed-Release Oral Suspension </span></td> </tr> <tr> <td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 1 Year to 5 Years </span></td><td align="center" class="Botrule Rrule" colspan="2" valign="top"><span class="Bold"> 6 Years to 11 Years </span></td> </tr> <tr> <td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 10 mg </span><span class="Bold"> once daily</span><span class="Bold"> (N = 8)</span></td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 10 mg </span><span class="Bold"> once daily</span><span class="Bold"> (N = 7)</span></td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 20 mg </span><span class="Bold"> once daily</span><span class="Bold"> (N = 6)</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">AUC (micromol∙h/L)<span class="Italics"><span class="Sup">1</span></span></td><td align="center" class="Botrule Rrule" valign="top">4.83</td><td align="center" class="Botrule Rrule" valign="top">3.70</td><td align="center" class="Botrule Rrule" valign="top">6.28</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">C<span class="Sub">max </span>(micromol/L)<span class="Italics"><span class="Sup">1</span></span></td><td align="center" class="Botrule Rrule">2.98</td><td align="center" class="Botrule Rrule">1.77</td><td align="center" class="Botrule Rrule" valign="top">3.73</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">t<span class="Sub">max </span>(h)<span class="Italics"><span class="Sup">2</span></span></td><td align="center" class="Botrule Rrule" valign="top">1.44</td><td align="center" class="Botrule Rrule" valign="top">1.79</td><td align="center" class="Botrule Rrule" valign="top">1.75</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">t<span class="Sub">½λz </span>(h)<span class="Italics"><span class="Sup">1</span></span></td><td align="center" class="Botrule Rrule" valign="top">0.74</td><td align="center" class="Botrule Rrule" valign="top">0.88</td><td align="center" class="Botrule Rrule" valign="top">0.73</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" valign="top">Cl/F (L/h)<span class="Italics"><span class="Sup">1</span></span></td><td align="center" class="Botrule Rrule" valign="top">5.99</td><td align="center" class="Botrule Rrule" valign="top">7.84</td><td align="center" class="Botrule Rrule" valign="top">9.22</td> </tr> </tbody> </table></div>

12 Years to 17 Years of Age

The pharmacokinetics of esomeprazole magnesium were studied in 28 adolescent patients with GERD aged 12 to 17 years inclusive, in a single center study. Patients were randomized to receive esomeprazole magnesium 20 mg or 40 mg once daily for 8 days. Mean Cmax and AUC values of esomeprazole were not affected by body weight or age; and more than dose-proportional increases in mean Cmax and AUC values were observed between the two dose groups in the study. Overall, esomeprazole magnesium pharmacokinetics in adolescent patients aged 12 to 17 years were similar to those observed in adult patients with symptomatic GERD. See Table 9.

<div class="scrollingtable"><table width="608px"> <caption> <span> Table 9: Comparison of Esomeprazole Pharmacokinetic Parameters Following Once Daily Dosing of Esomeprazole Magnesium Delayed-Release Capsules in Pediatric Patients 12 Years to 17 Years with GERD and Adults with Symptomatic GERD<span class="Sup">1</span></span> </caption> <colgroup> <col width="170"/> <col width="108"/> <col width="110"/> <col width="110"/> <col width="110"/> </colgroup> <tfoot> <tr class="First First Last Last"> <td align="left" colspan="5"> <p class="First First Footnote"> <span class="Sup">1. </span>Data obtained from two independent studies</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule"></td><td align="center" class="Botrule Rrule Toprule" colspan="4" valign="top"><span class="Bold"> Esomeprazole Magnesium Delayed-Release Capsules</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule"></td><td align="center" class="Botrule Rrule" colspan="2" valign="top"><span class="Bold"> 12 Years to 17 Years  (N=28)</span></td><td align="center" class="Botrule Rrule" colspan="2" valign="top"><span class="Bold"> Adults (N=36)</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> Parameter</span></td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 20 mg once daily for 8 days </span></td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 40 mg once daily for 8 days</span></td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 20 mg once daily for 5 days</span></td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> 40 mg once daily for 5 days</span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">AUC (micromol·h/L)</td><td align="center" class="Botrule Rrule" valign="top">3.65</td><td align="center" class="Botrule Rrule" valign="top">13.86</td><td align="center" class="Botrule Rrule" valign="top">4.2</td><td align="center" class="Botrule Rrule" valign="top">12.6</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">C<span class="Sub">max </span>(micromol/L)</td><td align="center" class="Botrule Rrule" valign="top">1.45</td><td align="center" class="Botrule Rrule" valign="top">5.13</td><td align="center" class="Botrule Rrule" valign="top">2.1</td><td align="center" class="Botrule Rrule" valign="top">4.7</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">t<span class="Sub">max </span>(h)</td><td align="center" class="Botrule Rrule" valign="top">2.00</td><td align="center" class="Botrule Rrule" valign="top">1.75</td><td align="center" class="Botrule Rrule" valign="top">1.6</td><td align="center" class="Botrule Rrule" valign="top">1.6</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">t<span class="Sub">½λz </span>(h)</td><td align="center" class="Botrule Rrule" valign="top">0.82</td><td align="center" class="Botrule Rrule" valign="top">1.22</td><td align="center" class="Botrule Rrule" valign="top">1.2</td><td align="center" class="Botrule Rrule" valign="top">1.5</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" colspan="5" valign="top">Data presented are geometric means for AUC, C<span class="Sub">max</span> and t<span class="Sub">½λz</span>, and median value for t<span class="Sub">max</span>.</td> </tr> </tbody> </table></div>

Male and Female Patients

The AUC and Cmax values of esomeprazole were slightly higher (13%) in females than in males at steady state when dosed orally. This increase in exposure is not considered clinically relevant.

Patients with Renal Impairment

The pharmacokinetics of esomeprazole magnesium in patients with renal impairment are not expected to be altered relative to healthy subjects as less than 1% of esomeprazole is excreted unchanged in urine.

Patients with Hepatic Impairment

The steady state pharmacokinetics of esomeprazole obtained after administration of esomeprazole magnesium delayed-release capsules 40 mg orally once daily to patients with mild (Child-Pugh Class A, n=4), moderate (Child-Pugh Class B, n=4), and severe (Child-Pugh Class C, n=4) hepatic impairment were compared to those obtained in 36 male and female GERD patients with normal liver function. In patients with mild and moderate hepatic impairment, the AUCs were within the range that could be expected in patients with normal liver function. In patients with severe hepatic impairment the AUCs were 2 to 3 times higher than in the patients with normal liver function [see Use in Specific Populations (8.6)].

Drug Interaction Studies

Effect of Esomeprazole/Omeprazole on Other Drugs

In vitro and in vivo studies have shown that esomeprazole is not likely to inhibit CYPs 1A2, 2A6, 2C9, 2D6, 2E1 and 3A4.

Antiretrovirals

For some antiretroviral drugs, such as rilpivirine, atazanavir and nelfinavir, decreased serum concentrations have been reported when given together with omeprazole [see Drug Interactions (7)].

Rilpivirine:

Following multiple doses of rilpivirine (150 mg, daily) and omeprazole (20 mg, daily), AUC was decreased by 40%, Cmax by 40%, and Cmin by 33% for rilpivirine [see Contraindications (4)].

Nelfinavir:

Following multiple doses of nelfinavir (1,250 mg, twice daily) and omeprazole (40 mg daily), AUC was decreased by 36% and 92%, Cmax by 37% and 89% and Cmin by 39% and 75% respectively for nelfinavir and M8.

Atazanavir:

Following multiple doses of atazanavir (400 mg, daily) and omeprazole (40 mg, daily, 2 hours before atazanavir), AUC was decreased by 94%, Cmax by 96%, and Cmin by 95%.

Saquinavir:

Following multiple dosing of saquinavir/ritonavir (1,000/100 mg) twice daily for 15 days with omeprazole 40 mg daily co-administered days 11 to 15. The AUC was increased by 82%, Cmax by 75%, and Cmin by 106%. The mechanism behind this interaction is not fully elucidated.

Clopidogrel

In a crossover study, healthy subjects were administered clopidogrel (300 mg loading dose followed by 75 mg per day as the maintenance dosage for 28 days) alone and with esomeprazole (40 mg orally once daily at the same time as clopidogrel) for 29 days. Exposure to the active metabolite of clopidogrel was reduced by 35% to 40% over this time period when clopidogrel and esomeprazole were administered together. Pharmacodynamic parameters were also measured and demonstrated that the change in inhibition of platelet aggregation was related to the change in the exposure to clopidogrel active metabolite [see Warnings and Precautions (5.7) and Drug Interactions (7)].

Mycophenolate Mofetil

Administration of omeprazole 20 mg twice daily for 4 days and a single 1,000 mg dose of MMF approximately one hour after the last dose of omeprazole to 12 healthy subjects in a cross-over study resulted in a 52% reduction in the Cmax and 23% reduction in the AUC of MPA [see Drug Interactions (7)].

Cilostazol

Omeprazole acts as an inhibitor of CYP2C19. Omeprazole, given in doses of 40 mg daily for one week to 20 healthy subjects in cross-over study, increased Cmax and AUC of cilostazol by 18% and 26% respectively. The Cmax and AUC of one of the active metabolites, 3,4-dihydro-cilostazol, which has 4 to 7 times the activity of cilostazol, were increased by 29% and 69%, respectively. Co-administration of cilostazol with omeprazole is expected to increase concentrations of cilostazol and the above mentioned active metabolite [see Drug Interactions (7)].

Diazepam

Co-administration of esomeprazole 30 mg and diazepam, a CYP2C19 substrate, resulted in a 45% decrease in clearance of diazepam. Increased plasma levels of diazepam were observed 12 hours after dosing and onwards. However, at that time, the plasma levels of diazepam were below the therapeutic interval, and thus this interaction is unlikely to be of clinical relevance.

Digoxin

Concomitant administration of omeprazole 20 mg once daily and digoxin in healthy subjects increased the bioavailability of digoxin by 10% (30% in two subjects) [see Drug Interactions (7)].

Other Drugs

Concomitant administration of esomeprazole and either naproxen (non-selective NSAID) did not identify any clinically relevant changes in the pharmacokinetic profiles of these NSAIDs.

Effect of Other Drugs on Esomeprazole/Omeprazole

St. John's Wort

In a cross-over study in 12 healthy male subjects, St. John's Wort (300 mg three times daily for 14 days) significantly decreased the systemic exposure of omeprazole in CYP2C19 poor metabolizers (Cmax and AUC both decreased by 38%) and extensive metabolizers (Cmax and AUC decreased by 50% and 44%, respectively) [see Drug Interactions (7)].

Voriconazole

Concomitant administration of omeprazole and voriconazole (a combined inhibitor of CYP2C19 and CYP3A4) resulted in more than doubling of the omeprazole exposure. When voriconazole (400 mg every 12 hours for one day, followed by 200 mg once daily for 6 days) was given with omeprazole (40 mg once daily for 7 days) to healthy subjects, the steady-state Cmax and AUC0-24 of omeprazole significantly increased: an average of 2 times (90% CI: 1.8, 2.6) and 4 times (90% CI: 3.3, 4.4), respectively, as compared to when omeprazole was given without voriconazole [see Drug Interactions (7)].

Other Drugs

Co-administration of esomeprazole with oral contraceptives, diazepam, phenytoin, quinidine, naproxen (non-selective NSAID) did not seem to change the pharmacokinetic profile of esomeprazole.

Esomeprazole magnesium, amoxicillin, and clarithromycin triple therapy has been shown to be active against most strains of Helicobacter pylori (H. pylori) in vitro and in clinical infections [see Indications and Usage (1) and Clinical Studies (14)].

Helicobacter pylori: Susceptibility testing of H. pylori isolates was performed for amoxicillin and clarithromycin using agar dilution methodology, and minimum inhibitory concentrations (MICs) were determined.

Pretreatment Resistance: Clarithromycin pretreatment resistance rate (MIC ≥ 1 mcg/mL) to H. pylori was 15% (66/445) at baseline in all treatment groups combined. A total of > 99% (394/395) of patients had H. pylori isolates that were considered to be susceptible (MIC ≤ 0.25 mcg/mL) to amoxicillin at baseline. One patient had a baseline H. pylori isolate with an amoxicillin MIC = 0.5 mcg/mL.

Clarithromycin Susceptibility Test Results and Clinical/Bacteriologic Outcomes: The baseline H. pylori clarithromycin susceptibility results and the H. pylori eradication results at the Day 38 visit are shown in Table 10:

<div class="scrollingtable"><table width="517"> <caption> <span> Table 10: Clarithromycin Susceptibility Test Results and Clinical/Bacteriological Outcomes1 for Triple Therapy (Esomeprazole Magnesium Delayed-Release Capsules 40 mg once daily, Amoxicillin 1,000 mg twice daily and Clarithromycin 500 mg twice daily for 10 days) </span> </caption> <colgroup> <col width="154"/> <col width="93"/> <col width="67"/> <col width="67"/> <col width="67"/> <col width="69"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="6"> <p class="First First Footnote"> <span class="Sup">1. </span>Includes only patients with pretreatment and post-treatment clarithromycin susceptibility test results</p> </td> </tr> <tr class="Last"> <td align="left" colspan="6"> <p class="First First Footnote"> <span class="Sup">2. </span>Susceptible (S) MIC ≤0.25 mcg/mL, Intermediate (I) MIC = 0.5 mcg/mL, Resistant (R) MIC ≥1.0 mcg/mL</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="center" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold"> Clarithromycin Pretreatment Results</span></td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"><span class="Italics">H. pylori </span></span><span class="Bold"> negative (Eradicated)</span></td><td align="center" class="Botrule Rrule Toprule" colspan="4" valign="top"><span class="Bold"><span class="Italics">H. pylori </span></span><span class="Bold"> positive (Not Eradicated) </span> <br/> <span class="Bold"> Post-treatment susceptibility </span> <br/> <span class="Bold"> results</span></td> </tr> <tr> <td class="Botrule Lrule Rrule" valign="top"></td><td class="Botrule Rrule" valign="top"></td><td align="center" class="Botrule Rrule" valign="top">S<span class="Italics"><span class="Sup">2</span></span></td><td align="center" class="Botrule Rrule" valign="top">I<span class="Italics"><span class="Sup">2</span></span></td><td align="center" class="Botrule Rrule" valign="top">R<span class="Italics"><span class="Sup">2</span></span></td><td align="center" class="Botrule Rrule" valign="top">No <br/> MIC</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Susceptible<span class="Italics"><span class="Sup">2</span></span>    182</td><td align="center" class="Botrule Rrule" valign="top">162</td><td align="center" class="Botrule Rrule" valign="top">4</td><td align="center" class="Botrule Rrule" valign="top">0</td><td align="center" class="Botrule Rrule" valign="top">2</td><td align="center" class="Botrule Rrule">14</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">Intermediate<span class="Italics"><span class="Sup">2</span></span>    1</td><td align="center" class="Botrule Rrule" valign="top">1</td><td align="center" class="Botrule Rrule" valign="top">0</td><td align="center" class="Botrule Rrule" valign="top">0</td><td align="center" class="Botrule Rrule" valign="top">0</td><td align="center" class="Botrule Rrule">0</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule">Resistant<span class="Italics"><span class="Sup">2</span></span>         29</td><td align="center" class="Botrule Rrule" valign="top">13</td><td align="center" class="Botrule Rrule" valign="top">1</td><td align="center" class="Botrule Rrule" valign="top">0</td><td align="center" class="Botrule Rrule" valign="top">13</td><td align="center" class="Botrule Rrule">2</td> </tr> </tbody> </table></div>

Patients not eradicated of H. pylori following triple therapy with esomeprazole magnesium, amoxicillin and clarithromycin will likely have clarithromycin resistant H. pylori isolates. Therefore, clarithromycin susceptibility testing should be done, when possible. Patients with clarithromycin resistant H. pylori should not be re-treated with a clarithromycin-containing regimen.

Amoxicillin Susceptibility Test Results and Clinical/Bacteriological Outcomes:

In patients treated with esomeprazole magnesium, amoxicillin and clarithromycin in clinical trials, 83% (176/212) of the patients who had pretreatment amoxicillin susceptible MICs (≤0.25 mcg/mL) were eradicated of H. pylori, and 17% (36/212) were not eradicated of H. pylori. Of the 36 patients who were not eradicated of H. pylori, 16 had no post-treatment susceptibility test results and 20 had post-treatment H. pylori isolates with amoxicillin susceptible MICs. Fifteen of the patients who were not eradicated of H. pylori also had post-treatment H. pylori isolates with clarithromycin resistant MICs. There were no patients with H. pylori isolates who developed treatment emergent resistance to amoxicillin.

Susceptibility Test for Helicobacter pylori: For susceptibility testing information about Helicobacter pylori, see Microbiology section in prescribing information for clarithromycin and amoxicillin.

Effects on Gastrointestinal Microbial Ecology: Decreased gastric acidity due to any means, including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with PPIs may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile in hospitalized patients.

CYP2C19, a polymorphic enzyme, is involved in the metabolism of esomeprazole. The CYP2C19*1 allele is fully functional while the CYP2C19*2 and *3 alleles are nonfunctional. There are other alleles associated with no or reduced enzymatic function. Patients carrying two fully functional alleles are extensive metabolizers and those carrying two loss-of-function alleles are poor metabolizers. The systemic exposure to esomeprazole varies with a patient's metabolism status: poor metabolizers > intermediate metabolizers > extensive metabolizers. Approximately 3% of Caucasians and 15 to 20% of Asians are CYP2C19 poor metabolizers.

Systemic esomeprazole exposures were modestly higher (approximately 17%) in CYP2C19 intermediate metabolizers (IM; n=6) compared to extensive metabolizers (EM; n=17) of CYP2C19. Similar pharmacokinetic differences were noted across these genotypes in a study of Chinese healthy subjects that included 7 EMs and 11 IMs. There is very limited pharmacokinetic information for poor metabolizers (PM) from these studies.

At steady state following once daily administration of esomeprazole 40 mg, the ratio of AUC in poor metabolizers to AUC in the rest of the population (EMs) is approximately 1.5. This change in exposure is not considered clinically meaningful.

The carcinogenic potential of esomeprazole magnesium was assessed using studies of omeprazole, of which esomeprazole is an enantiomer. In two 24-month oral carcinogenicity studies in rats, omeprazole at daily doses of 1.7, 3.4, 13.8, 44, and 140.8 mg/kg/day (about 0.4 to 34 times the human dose of 40 mg/day expressed on a body surface area basis) produced gastric ECL cell carcinoids in a dose-related manner in both male and female rats; the incidence of this effect was markedly higher in female rats, which had higher blood levels of omeprazole. Gastric carcinoids seldom occur in the untreated rat. In addition, ECL cell hyperplasia was present in all treated groups of both sexes. In one of these studies, female rats were treated with 13.8 mg omeprazole/kg/day (about 3.4 times the human dose of 40 mg/day on a body surface area basis) for 1 year, then followed for an additional year without the drug. No carcinoids were seen in these rats. An increased incidence of treatment-related ECL cell hyperplasia was observed at the end of 1 year (94% treated vs. 10% controls). By the second year the difference between treated and control rats was much smaller (46% vs. 26%) but still showed more hyperplasia in the treated group. Gastric adenocarcinoma was seen in one rat (2%). No similar tumor was seen in male or female rats treated for 2 years. For this strain of rat no similar tumor has been noted historically, but a finding involving only one tumor is difficult to interpret. A 78-week mouse carcinogenicity study of omeprazole did not show increased tumor occurrence, but the study was not conclusive.

Esomeprazole was negative in the Ames mutation test, in the in vivo rat bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test. Esomeprazole, however, was positive in the in vitro human lymphocyte chromosome aberration test. Omeprazole was positive in the in vitro human lymphocyte chromosome aberration test, the in vivo mouse bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test.

The potential effects of esomeprazole on fertility and reproductive performance were assessed using omeprazole studies. Omeprazole at oral doses up to 138 mg/kg/day in rats (about 34 times the human dose of 40 mg/day on a body surface area basis) was found to have no effect on reproductive performance of parental animals.

Reproduction Studies

Reproduction studies have been performed in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at oral doses up to 86 mg/kg/day (about 42 times an oral human dose of 40 mg on a body surface area basis) and have revealed no evidence of impaired fertility or harm to the fetus due to esomeprazole [see Use in  Specific Populations (8.1)].

Juvenile Animal Study

A 28-day toxicity study with a 14-day recovery phase was conducted in juvenile rats with esomeprazole magnesium at doses of 70 to 280 mg/kg/day (about 17 to 68 times a daily oral human dose of 40 mg on a body surface area basis). An increase in the number of deaths at the high dose of 280 mg/kg/day was observed when juvenile rats were administered esomeprazole magnesium from postnatal day 7 through postnatal day 35. In addition, doses equal to or greater than 140 mg/kg/day (about 34 times a daily oral human dose of 40 mg on a body surface area basis), produced treatment-related decreases in body weight (approximately 14%) and body weight gain, decreases in femur weight and femur length, and affected overall growth. Comparable findings described above have also been observed in this study with another esomeprazole salt, esomeprazole strontium, at equimolar doses of esomeprazole.

The healing rates of esomeprazole magnesium delayed-release capsules 40 mg, esomeprazole magnesium delayed-release capsules 20 mg, and omeprazole delayed-release capsules 20 mg (the approved dose for this indication) once daily were evaluated in adult patients with endoscopically diagnosed EE in four multicenter, double-blind, randomized studies. The healing rates at Weeks 4 and 8 were evaluated and are shown in Table 11:

<div class="scrollingtable"><table width="97%"> <caption> <span> Table 11: EE Healing Rate (Life-Table Analysis) in Adults with EE Treated with Esomeprazole Magnesium Delayed-Release Capsules or Omeprazole Delayed-Release Capsules Once Daily in Four Clinical Studies </span> </caption> <colgroup> <col width="10%"/> <col width="12%"/> <col width="39%"/> <col width="11%"/> <col width="11%"/> <col width="15%"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="6"> <p class="First First Footnote">N.S. = not significant (p &gt; 0.05).</p> </td> </tr> <tr class="Last"> <td align="left" colspan="6"> <p class="First First Footnote"> <span class="Sup">1</span>. log-rank test vs. omeprazole 20 mg</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td class="Botrule Lrule Rrule Toprule"></td><td class="Botrule Rrule Toprule" valign="top"></td><td class="Botrule Rrule Toprule"></td><td align="center" class="Botrule Rrule Toprule" colspan="2"><span class="Bold">EE Healing Rates</span></td><td class="Botrule Rrule Toprule"></td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule"><span class="Bold">Study</span></td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold">No. of Patients</span></td><td align="left" class="Botrule Rrule"><span class="Bold">Treatment Group</span></td><td align="center" class="Botrule Rrule"><span class="Bold">Week 4</span></td><td align="center" class="Botrule Rrule"><span class="Bold">Week 8</span></td><td align="center" class="Botrule Rrule"><span class="Bold">Significance Level<span class="Italics"><span class="Sup">1</span></span></span></td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top">1</td><td align="center" class="Botrule Rrule" valign="top">588<br/> 588</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 20 mg <br/> Omeprazole 20 mg</td><td align="center" class="Botrule Rrule" valign="top">68.7%<br/> 69.5%</td><td align="center" class="Botrule Rrule" valign="top">90.6%<br/> 88.3%</td><td align="left" class="Botrule Rrule" valign="top">N.S.</td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top">2</td><td align="center" class="Botrule Rrule" valign="top">654<br/> 656<br/> 650</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 40 mg<br/> Esomeprazole magnesium 20 mg<br/> Omeprazole 20 mg</td><td align="center" class="Botrule Rrule" valign="top">75.9%<br/> 70.5%<br/> 64.7%</td><td align="center" class="Botrule Rrule" valign="top">94.1%<br/> 89.9%<br/> 86.9%</td><td align="left" class="Botrule Rrule" valign="top">p &lt; 0.001<br/> p &lt; 0.05</td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top">3</td><td align="center" class="Botrule Rrule" valign="top">576<br/> 572</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 40 mg<br/> Omeprazole 20 mg</td><td align="center" class="Botrule Rrule" valign="top">71.5%<br/> 68.6%</td><td align="center" class="Botrule Rrule" valign="top">92.2%<br/> 89.8%</td><td align="left" class="Botrule Rrule" valign="top">N.S.</td> </tr> <tr class="Last"> <td align="center" class="Botrule Lrule Rrule" valign="top">4</td><td align="center" class="Botrule Rrule" valign="top">1216<br/> 1209</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 40 mg<br/> Omeprazole 20 mg</td><td align="center" class="Botrule Rrule" valign="top">81.7%<br/> 68.7%</td><td align="center" class="Botrule Rrule" valign="top">93.7%<br/> 84.2%</td><td align="left" class="Botrule Rrule" valign="top">p &lt; 0.001</td> </tr> </tbody> </table></div>

In these same studies of patients with EE, sustained heartburn resolution and time to sustained heartburn resolution were evaluated and are shown in Table 12:

<div class="scrollingtable"><table width="97%"> <caption> <span> Table 12: Sustained Resolution<span class="Sup">1</span> of Heartburn in Adults with EE Treated with Esomeprazole Magnesium Delayed-Release Capsules or Omeprazole Delayed-Release Capsules Once Daily in Four Clinical Studies </span> </caption> <colgroup> <col width="8%"/> <col width="9%"/> <col width="39%"/> <col width="11%"/> <col width="12%"/> <col width="18%"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="6"> <p class="First First Footnote"> <span class="Sup">1.  </span>Defined as 7 consecutive days with no heartburn reported in daily patient diary.</p> </td> </tr> <tr> <td align="left" colspan="6"> <p class="First First Footnote"> <span class="Sup">2. </span>Defined as the cumulative proportion of patients who have reached the start of sustained resolution.</p> </td> </tr> <tr> <td align="left" colspan="6"> <p class="First First Footnote"> <span class="Sup">3.  </span>log-rank test vs. omeprazole 20 mg.</p> </td> </tr> <tr class="Last"> <td align="left" colspan="6"> <p class="First First Footnote">N.S. = not significant (p &gt; 0.05).</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td class="Botrule Lrule Rrule Toprule" valign="top"></td><td class="Botrule Rrule Toprule" valign="top"></td><td class="Botrule Rrule Toprule" valign="top"></td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"><span class="Bold">Cumulative Percent<span class="Italics"><span class="Sup">2</span></span> with Sustained Resolution</span></td><td class="Botrule Rrule Toprule" valign="top"></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="bottom"><span class="Bold">Study</span></td><td align="left" class="Botrule Rrule" valign="top"><span class="Bold">No. of </span> <br/> <span class="Bold"> Patients</span></td><td align="left" class="Botrule Rrule" valign="bottom"><span class="Bold">Treatment Groups</span></td><td align="left" class="Botrule Rrule" valign="bottom"><span class="Bold">Day 14</span></td><td align="left" class="Botrule Rrule" valign="bottom"><span class="Bold">Day 28</span></td><td align="left" class="Botrule Rrule" valign="bottom"><span class="Bold">Significance Level<span class="Italics"><span class="Sup">3</span></span></span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">1</td><td align="left" class="Botrule Rrule" valign="top">573<br/> 555</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 20 mg<br/> Omeprazole 20 mg</td><td align="left" class="Botrule Rrule" valign="top">64.3%<br/> 64.1%</td><td align="left" class="Botrule Rrule" valign="top">72.7%<br/> 70.9%</td><td align="left" class="Botrule Rrule" valign="top">N.S.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">2</td><td align="left" class="Botrule Rrule" valign="top">621<br/> 620<br/> 626</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 40 mg <br/> Esomeprazole magnesium 20 mg <br/> Omeprazole 20 mg</td><td align="left" class="Botrule Rrule" valign="top">64.8%<br/> 62.9%<br/> 56.5%</td><td align="left" class="Botrule Rrule" valign="top">74.2%<br/> 70.1%<br/> 66.6%</td><td align="left" class="Botrule Rrule" valign="top">p &lt;0.001<br/> N.S.</td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">3</td><td align="left" class="Botrule Rrule" valign="top">568<br/> 551</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 40 mg <br/> Omeprazole 20 mg</td><td align="left" class="Botrule Rrule" valign="top">65.4%<br/> 65.5%</td><td align="left" class="Botrule Rrule" valign="top">73.9%<br/> 73.1%</td><td align="left" class="Botrule Rrule" valign="top">N.S.</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule" valign="top">4</td><td align="left" class="Botrule Rrule" valign="top">1187<br/> 1188</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 40 mg <br/> Omeprazole 20 mg</td><td align="left" class="Botrule Rrule" valign="top">67.6%<br/> 62.5%</td><td align="left" class="Botrule Rrule" valign="top">75.1%<br/> 70.8%</td><td align="left" class="Botrule Rrule" valign="top">p &lt;0.001</td> </tr> </tbody> </table></div>

In these four studies, the range of median days to the start of sustained resolution (defined as 7 consecutive days with no heartburn) was 5 days for esomeprazole magnesium 40 mg, 7 to 8 days for esomeprazole magnesium 20 mg and 7 to 9 days for omeprazole 20 mg.

There are no comparisons of 40 mg of esomeprazole magnesium with 40 mg of omeprazole in clinical trials assessing either healing or symptomatic relief of EE.

Two multicenter, randomized, double-blind placebo-controlled 4-arm studies were conducted in adult patients with endoscopically confirmed, healed EE to evaluate esomeprazole magnesium delayed-release capsules 40 mg (n=174), 20 mg (n=180), 10 mg (n=168) or placebo (n=171) once daily over six months of treatment.

No additional clinical benefit was seen with esomeprazole magnesium 40 mg over esomeprazole magnesium 20 mg. Esomeprazole magnesium 40 mg once daily is not a recommended regimen for the maintenance of healing of EE in adults.

The percentages of patients that maintained healing of EE at the various time points are shown in the Figures 2 and 3:

Figure 2: Maintenance of Healing Rates of EE in Adults by Month (Study 177)

Figure 3:Maintenance of EE Healing Rates in Adults by Month (Study 178)

Patients remained in remission significantly longer and the number of recurrences of EE was significantly less in patients treated with esomeprazole magnesium compared to placebo.

In both studies, the proportion of patients on esomeprazole magnesium who remained in remission and were free of heartburn and other GERD symptoms was well differentiated from placebo.

In a third multicenter open label study of 808 patients treated for 12 months with esomeprazole magnesium 40 mg, the percentage of patients that maintained healing of EE was 93.7% for six months and 89.4% for one year.

Two multicenter, randomized, double-blind, placebo-controlled studies were conducted in a total of 717 adult patients comparing four weeks of treatment with esomeprazole magnesium delayed-release capsules 20 mg or 40 mg once daily versus placebo for resolution of GERD symptoms. Patients had at least a 6-month history of heartburn episodes, no EE by endoscopy, and heartburn on at least four of the seven days immediately preceding randomization.

The percentage of patients that were symptom-free of heartburn was significantly higher in the esomeprazole magnesium groups compared to placebo at all follow-up visits (Weeks 1, 2, and 4).

No additional clinical benefit was seen with esomeprazole magnesium 40 mg over esomeprazole magnesium 20 mg. Esomeprazole magnesium 40 mg once daily is not a recommended regimen for the treatment of symptomatic GERD in adults.

The percent of patients symptom-free of heartburn by day are shown in the Figures 4 and 5:

Figure 4: Percent of Patients Symptom-Free of Heartburn by Day (Study 225)

Figure 5: Percent of Patients Symptom-Free of Heartburn by Day (Study 226)

In three European symptomatic GERD trials, esomeprazole magnesium 20 mg and 40 mg and omeprazole 20 mg were evaluated. No significant treatment related differences were seen.

1 Year to 11 Years of Age

In a multicenter, parallel-group study, 109 pediatric patients with a history of endoscopically-proven GERD (1 year to 11 years of age; 53 female; 89 Caucasian, 19 Black, 1 Other) were treated with esomeprazole magnesium for delayed-release oral suspension once daily for up to 8 weeks to evaluate safety and tolerability. Dosing by patient weight was as follows:

Patients were endoscopically characterized as to the presence or absence of EE.

Of the 109 patients, 53 had EE at baseline (51 had mild, 1 moderate, and 1 severe esophagitis). Although most of the patients who had a follow up endoscopy at the end of 8 weeks of treatment healed, spontaneous healing cannot be ruled out because these patients had low grade EE prior to treatment, and the trial did not include a concomitant control.

12 Years to 17 Years of Age

In a multicenter, randomized, double-blind, parallel-group study, 149 adolescent patients (12 to 17 years of age; 89 female; 124 Caucasian, 15 Black, 10 Other) with clinically diagnosed GERD were treated with esomeprazole magnesium delayed-release capsules 20 mg or 40 mg once daily for up to 8 weeks to evaluate safety and tolerability. Patients were not endoscopically characterized as to the presence or absence of EE.

Two multicenter, double-blind, placebo-controlled studies were conducted in adult patients at risk of developing gastric and/or duodenal ulcers associated with continuous use of non-selective and COX-2 selective NSAIDs. A total of 1,429 patients were randomized across the 2 studies. Patients ranged in age from 19 to 89 (median age 66 years) with 71% female, 29% male; 83% Caucasian, 5% Black, 4% Asian, and 8% Others. At baseline, the patients in these studies were endoscopically confirmed not to have ulcers but were determined to be at risk for ulcer occurrence due to their age (at least 60 years) and/or history of a documented gastric or duodenal ulcer within the past 5 years. Patients receiving NSAIDs and treated with esomeprazole magnesium delayed-release capsules 20 mg or 40 mg once daily experienced significant reduction in gastric ulcer occurrences relative to placebo treatment at 26 weeks. See Table 13. No additional benefit was seen with esomeprazole magnesium 40 mg over esomeprazole magnesium 20 mg. Esomeprazole magnesium 40 mg once daily is not a recommended regimen for the risk reduction of NSAID-associated gastric ulcer in adults. These studies did not demonstrate significant reduction in the development of NSAID-associated duodenal ulcer due to the low incidence.

<div class="scrollingtable"><table width="607"> <caption> <span> Table 13: Cumulative Percentage of Patients at Least 60 Years of Age Taking NSAIDS Without Gastric Ulcers at 26 Weeks in Two Randomized Placebo-Controlled Studies          </span> </caption> <colgroup> <col width="56"/> <col width="76"/> <col width="266"/> <col width="209"/> </colgroup> <tfoot> <tr class="First First Last Last"> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">1. </span>%= Life Table Estimate. Significant difference from placebo (p&lt;0.01).</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top">Study</td><td align="left" class="Botrule Rrule Toprule" valign="top">No. of Patients</td><td align="left" class="Botrule Rrule Toprule" valign="top">Treatment Group</td><td align="left" class="Botrule Rrule Toprule" valign="top">% of Patients Remaining <br/> Gastric Ulcer Free<span class="Italics"><span class="Sup">1</span></span></td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">1</td><td align="left" class="Botrule Rrule" valign="top">191<br/> 194<br/> 184</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 20 mg Esomeprazole magnesium 40 mg<br/> Placebo</td><td align="left" class="Botrule Rrule" valign="top">95.4<br/> 96.7<br/> 88.2</td> </tr> <tr class="Last"> <td align="left" class="Botrule Lrule Rrule">2</td><td align="left" class="Botrule Rrule" valign="top">267<br/> 271<br/> 257</td><td align="left" class="Botrule Rrule" valign="top">Esomeprazole magnesium 20 mg<br/> Esomeprazole magnesium 40 mg<br/> Placebo</td><td align="left" class="Botrule Rrule" valign="top">94.7<br/> 95.3<br/> 83.3</td> </tr> </tbody> </table></div>

Two multicenter, randomized, double-blind studies were conducted in adult patients using a 10- day treatment regimen of triple therapy (esomeprazole magnesium, amoxicillin and clarithromycin). The first study (191) compared esomeprazole magnesium delayed-release capsules 40 mg once daily in combination with amoxicillin 1,000 mg twice daily and clarithromycin 500 mg twice daily to esomeprazole magnesium delayed-release capsules 40 mg once daily plus clarithromycin 500 mg twice daily. The second study (193) compared esomeprazole magnesium delayed-release capsules 40 mg once daily in combination with amoxicillin 1,000 mg twice daily and clarithromycin 500 mg twice daily to esomeprazole magnesium delayed-release capsules 40 mg once daily. H. pylori eradication rates, defined as at least two negative tests and no positive tests from CLOtest®, histology and/or culture, at 4 weeks post-therapy were significantly higher in the esomeprazole magnesium, amoxicillin and clarithromycin group than in the esomeprazole magnesium and clarithromycin group or the esomeprazole magnesium alone group. The results are shown in Table 14:

<div class="scrollingtable"><table width="100%"> <caption> <span>Table 14: H. pylori Eradication Rates at 4 Weeks after 10 Day Treatment Regimen % of Adult Patients Cured [95% Confidence Interval] (Number of Patients)</span> </caption> <colgroup> <col width="25%"/> <col width="25%"/> <col width="25%"/> <col width="25%"/> </colgroup> <tfoot> <tr class="First"> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">1.</span> Patients were included in the analysis if they had <span class="Italics">H. pylori </span> infection documented at baseline, had at least one endoscopically verified duodenal ulcer ≥0.5 cm in diameter at baseline or had a documented history of duodenal ulcer disease within the past 5 years, and were not protocol violators. Patients who dropped out of the study due to an adverse reaction related to the study drug were included in the analysis as not <span class="Italics">H. pylori </span> eradicated.</p> </td> </tr> <tr> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">2.</span> Patients were included in the analysis if they had documented <span class="Italics">H. pylori </span> infection at baseline, had at least one documented duodenal ulcer at baseline, or had a documented history of duodenal ulcer disease, and took at least one dose of study medication. All dropouts were included as not <span class="Italics">H. pylori </span> eradicated.</p> </td> </tr> <tr> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">3.</span> p &lt;0.05 compared to esomeprazole magnesium plus clarithromycin.</p> </td> </tr> <tr class="Last"> <td align="left" colspan="4"> <p class="First First Footnote"> <span class="Sup">4. </span>p &lt;0.05 compared to esomeprazole magnesium alone.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="left" valign="top">Study</td><td align="left" valign="top">Treatment Group</td><td align="left" valign="top">Per-Protocol<span class="Italics"><span class="Sup">1</span></span></td><td align="left" valign="top">Intent-to-Treat<span class="Italics"><span class="Sup">2</span></span></td> </tr> <tr> <td align="left" valign="top">191</td><td align="left" valign="top">Esomeprazole magnesium, amoxicillin and<br/> clarithromycin</td><td align="left" valign="top">84%<span class="Italics"><span class="Sup">3</span></span> <br/> [78, 89]<br/> (n=196)</td><td align="left" valign="top">77%<span class="Italics"><span class="Sup">3</span></span> <br/> [71, 82]<br/> (n=233)</td> </tr> <tr> <td valign="top"></td><td align="left" valign="top">Esomeprazole magnesium and clarithromycin</td><td align="left" valign="top">55%<br/> [48, 62]<br/> (n=187)</td><td align="left" valign="top">52%<br/> [45, 59]<br/> (n=215)</td> </tr> <tr> <td align="left" valign="top">193</td><td align="left" valign="top">Esomeprazole magnesium, amoxicillin and<br/> clarithromycin</td><td align="left" valign="top">85%<span class="Italics"><span class="Sup">4</span></span> <br/> [74, 93]<br/> (n=67)</td><td align="left" valign="top">78%<span class="Italics"><span class="Sup">4</span></span> <br/> [67, 87]<br/> (n=74)</td> </tr> <tr class="Last"> <td valign="top"></td><td align="left" valign="top">Esomeprazole magnesium</td><td align="left" valign="top">5%<br/> [0, 23]<br/> (n=22)</td><td align="left" valign="top">4%<br/> [0, 21]<br/> (n=24)</td> </tr> </tbody> </table></div>

The percentage of patients with a healed baseline duodenal ulcer by 4 weeks after the 10-day treatment regimen in the esomeprazole magnesium, amoxicillin and clarithromycin group was 75% (n=156) and 57% (n=60) respectively, in the 191 and 193 studies (per-protocol analysis).

In a multicenter, open-label dose-escalation study of 21 adult patients (15 males and 6 females, 18 Caucasian and 3 Black, mean age of 56 years) with pathological hypersecretory conditions, such as Zollinger-Ellison Syndrome, esomeprazole magnesium significantly inhibited gastric acid secretion. The initial dosage of esomeprazole magnesium delayed-release capsules was 40 mg twice daily in 19 patients and 80 mg twice daily in 2 patients. Total daily doses ranging from 80 mg to 240 mg for 12 months maintained gastric acid output below the target levels of 10 mEq/h in patients without prior gastric acid-reducing surgery and below 5 mEq/hr in patients with prior gastric acid-reducing surgery. At the Month 12 final visit, 18/20 (90%) patients had Basal Acid Output (BAO) under satisfactory control (median BAO = 0.17 mmol/hr). Of the 18 patients evaluated with a starting dose of esomeprazole magnesium 40 mg twice daily, 13 (72%) had their BAO controlled with the original dosing regimen at the final visit. See Table 15.

<div class="scrollingtable"><table width="100%"> <caption> <span> Table 15: Adequate Acid Suppression at Final Visit by Dosage Regimen in Adult Patients with Pathological Hypersecretory Conditions </span> </caption> <colgroup> <col width="45%"/> <col width="54%"/> </colgroup> <tfoot> <tr class="First First Last Last"> <td align="left" colspan="2"> <p class="First First Footnote"> <span class="Sup">1. </span>One patient was not evaluated.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr class="First"> <td align="center" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold">Esomeprazole Magnesium dose at the Month 12 visit</span></td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold">BAO under adequate control at the Month 12 visit (N=20)<span class="Italics"><span class="Sup">1</span></span></span></td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top">40 mg twice daily</td><td align="center" class="Botrule Rrule" valign="top">13/15</td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top">80 mg twice daily</td><td align="center" class="Botrule Rrule" valign="top">4/4</td> </tr> <tr class="Last"> <td align="center" class="Botrule Lrule Rrule" valign="top">80 mg three times daily</td><td align="center" class="Botrule Rrule" valign="top">1/1</td> </tr> </tbody> </table></div>

Esomeprazole Magnesium For Delayed-Release Oral Suspension is supplied as a unit dose child-resistant packet containing a light yellow, free flow granules, consisting of off-white to cream esomeprazole pellets and pale yellow inactive granules. Esomeprazole magnesium for delayed-release oral suspension unit dose packets are supplied as follows:

{ "type": "p", "children": [], "text": "Esomeprazole Magnesium For Delayed-Release Oral Suspension is supplied as a unit dose child-resistant packet containing a light yellow, free flow granules, consisting of off-white to cream esomeprazole pellets and pale yellow inactive granules. Esomeprazole magnesium for delayed-release oral suspension unit dose packets are supplied as follows:" }

Unit dose packages of 30: 2.5 mg esomeprazole packets      NDC 13668-546-94Unit dose packages of 30: 5 mg esomeprazole packets         NDC 13668-547-94Unit dose packages of 30: 20 mg esomeprazole packets       NDC 13668-549-94Unit dose packages of 30: 40 mg esomeprazole packets       NDC 13668-550-94

{ "type": "p", "children": [], "text": "Unit dose packages of 30: 2.5 mg esomeprazole packets      NDC 13668-546-94Unit dose packages of 30: 5 mg esomeprazole packets         NDC 13668-547-94Unit dose packages of 30: 20 mg esomeprazole packets       NDC 13668-549-94Unit dose packages of 30: 40 mg esomeprazole packets       NDC 13668-550-94" }

Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). [See USP Controlled Room Temperature].

{ "type": "p", "children": [], "text": "Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). [See USP Controlled Room Temperature]." }

Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use).

{ "type": "p", "children": [], "text": "\nAdvise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use)." }

Acute Tubulointerstitial Nephritis

{ "type": "p", "children": [], "text": "\nAcute Tubulointerstitial Nephritis \n" }

Advise the patient or caregiver to call the patient's healthcare provider immediately if they experience signs and/or symptoms associated with suspected acute TIN [see Warnings and Precautions (5.2)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to call the patient's healthcare provider immediately if they experience signs and/or symptoms associated with suspected acute TIN [see Warnings and Precautions (5.2)]." }

Clostridium difficile-Associated Diarrhea

{ "type": "p", "children": [], "text": "\nClostridium difficile-Associated Diarrhea \n" }

Advise the patient or caregiver to immediately call the patient's healthcare provider if they experience diarrhea that does not improve [see Warnings and Precautions (5.3)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to immediately call the patient's healthcare provider if they experience diarrhea that does not improve [see Warnings and Precautions (5.3)]." }

Bone Fracture

{ "type": "p", "children": [], "text": "\nBone Fracture \n" }

Advise the patient or caregiver to report any fractures, especially of the hip, wrist or spine, to the patient's healthcare provider [see Warnings and Precautions (5.4)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any fractures, especially of the hip, wrist or spine, to the patient's healthcare provider [see Warnings and Precautions (5.4)]." }

Severe Cutaneous Adverse Reactions

{ "type": "p", "children": [], "text": "\nSevere Cutaneous Adverse Reactions\n" }

Advise the patient or caregiver to discontinue esomeprazole magnesium and immediately call the patient’s healthcare provider for at first appearance of a severe cutaneous adverse reaction or other sign of hypersensitivity signs or symptoms associated with Severe Cutaneous Adverse Reactions [see Warnings and Precautions (5.5)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to discontinue esomeprazole magnesium and immediately call the patient’s healthcare provider for at first appearance of a severe cutaneous adverse reaction or other sign of hypersensitivity signs or symptoms associated with Severe Cutaneous Adverse Reactions [see Warnings and Precautions (5.5)]." }

Cutaneous and Systemic Lupus Erythematosus

{ "type": "p", "children": [], "text": "\nCutaneous and Systemic Lupus Erythematosus \n" }

Advise the patient or caregiver to immediately call the patient's healthcare provider for any new or worsening of symptoms associated with cutaneous or systemic lupus erythematosus [see Warnings and Precautions (5.6)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to immediately call the patient's healthcare provider for any new or worsening of symptoms associated with cutaneous or systemic lupus erythematosus [see Warnings and Precautions (5.6)]. \n" }

Cyanocobalamin (Vitamin B-12) Deficiency

{ "type": "p", "children": [], "text": "\nCyanocobalamin (Vitamin B-12) Deficiency \n" }

Advise the patient or caregiver to report any clinical symptoms that may be associated with cyanocobalamin deficiency to the patient's healthcare provider if they have been receiving esomeprazole magnesium for longer than 3 years [see Warnings and Precautions (5.8)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any clinical symptoms that may be associated with cyanocobalamin deficiency to the patient's healthcare provider if they have been receiving esomeprazole magnesium for longer than 3 years [see Warnings and Precautions (5.8)]." }

Hypomagnesemia and Mineral Metabolism

{ "type": "p", "children": [], "text": "\nHypomagnesemia and Mineral Metabolism\n" }

Advise the patient or caregiver to report any clinical symptoms that may be associated with hypomagnesemia, hypocalcemia, and/or hypokalemia to the patient's healthcare provider, if they have been receiving esomeprazole magnesium for at least 3 months [see Warnings and Precautions (5.9)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report any clinical symptoms that may be associated with hypomagnesemia, hypocalcemia, and/or hypokalemia to the patient's healthcare provider, if they have been receiving esomeprazole magnesium for at least 3 months [see Warnings and Precautions (5.9)]." }

Drug Interactions

{ "type": "p", "children": [], "text": "\nDrug Interactions \n" }

Advise the patient or caregiver to report to their healthcare provider if starting treatment with rilpivirine-containing products, clopidogrel, St. John's Wort or rifampin; or, if they take high-dose methotrexate [see Contraindications (4), Warnings and Precautions (5.7, 5.10, 5.12)].

{ "type": "p", "children": [], "text": "Advise the patient or caregiver to report to their healthcare provider if starting treatment with rilpivirine-containing products, clopidogrel, St. John's Wort or rifampin; or, if they take high-dose methotrexate [see Contraindications (4), Warnings and Precautions (5.7, 5.10, 5.12)].\n" }

Administration

{ "type": "p", "children": [], "text": "\nAdministration\n" }

{ "type": "ul", "children": [ "Take esomeprazole magnesium for delayed-release oral suspension at least one hour before meals.", "Antacids may be used concomitantly with esomeprazole magnesium for delayed-release oral suspension.", "Administer esomeprazole magnesium for delayed-release oral suspension orally or via a nasogastric or gastric tube, as described in the Instructions for Use. \n" ], "text": "" }

Trademarks are the property of their respective owners.

{ "type": "p", "children": [], "text": "\nTrademarks are the property of their respective owners." }

Manufactured by:

{ "type": "p", "children": [], "text": "\nManufactured by:\n" }

TORRENT PHARMACEUTICALS LTD., INDIA.

{ "type": "p", "children": [], "text": "TORRENT PHARMACEUTICALS LTD., INDIA." }

Manufactured for:

{ "type": "p", "children": [], "text": "\nManufactured for:\n" }

TORRENT PHARMA INC., Basking Ridge, NJ 07920.

{ "type": "p", "children": [], "text": "TORRENT PHARMA INC., Basking Ridge, NJ 07920." }

8070586                                                                                               Revised:September 2024

{ "type": "p", "children": [], "text": "8070586                                                                                               Revised:September 2024" }

<div class="scrollingtable"><table width="100%"> <caption> <span></span> </caption> <tbody class="Headless"> <tr class="First"> <td class="Botrule Lrule Rrule Toprule"> <p class="First"> <span class="Bold">MEDICATION GUIDE</span> </p> <p></p> <p> <span class="Bold">Esomeprazole Magnesium (es-ho-MEP-ra-zole mag-NEE-zee-um) </span> </p> <p> <span class="Bold">for Delayed-Release Oral Suspension</span> </p> </td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"> <p class="First"> <span class="Bold">What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension?</span> <br/> <span class="Bold">Esomeprazole magnesium for delayed-release oral suspension may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor.</span> <br/> <span class="Bold">Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including:</span> </p> <ul> <li> <span class="Bold">A type of kidney problem (acute tubulointerstitial nephritis). </span>Some people who take proton pump inhibitor (PPI) medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop a kidney problem called acute tubulointerstitial nephritis that can happen at any time during treatment with esomeprazole magnesium for delayed-release oral suspension. Call your doctor right away if you have a decrease in the amount that you urinate or if you have blood in your urine.</li> <li> <span class="Bold">Diarrhea caused by an infection (<span class="Italics">Clostridium difficile</span>) in your intestines. </span>Call your doctor right away if you have watery stools or stomach pain that does not go away. You may or may not have a fever.</li> <li> <span class="Bold">Bone fractures (hip, wrist, or spine). </span>Bone fractures in the hip, wrist, or spine may happen in people who take multiple daily doses of PPI medicines and for a long period of time (a year or longer). Tell your doctor if you have a bone fracture, especially in the hip, wrist, or spine.</li> <li> <span class="Bold">Certain types of lupus erythematosus. </span>Lupus erythematosus is an autoimmune disorder (the body’s immune cells attack other cells or organs in the body). Some people who take PPI medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop certain types of lupus erythematosus or have worsening of the lupus they already have. Call your doctor right away if you have new or worsening joint pain or a rash on your cheeks or arms that gets worse in the sun.</li> </ul> <p>Talk to your doctor about your risk of these serious side effects.</p> <p>Esomeprazole magnesium for delayed-release oral suspension can have other serious side effects. See <span class="Bold">“What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension?”</span> </p> </td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"> <p class="First"> <span class="Bold">What is esomeprazole magnesium for delayed-release oral suspension?</span> </p> <p>A prescription medicine called a proton pump inhibitor (PPI) used to reduce the amount of acid in your stomach.<br/>Esomeprazole magnesium delayed-release oral suspension is used in adults for:</p> <ul> <li>4 to 8 weeks for the healing and symptom relief of acid-related damage to the esophagus (erosive esophagitis or EE). Your doctor may prescribe another 4 to 8 weeks of esomeprazole magnesium for delayed-release oral suspension in patients whose EE does not heal.</li> <li>maintaining healing of EE.</li> <li>4 to 8 weeks to treat heartburn and other symptoms that happen with gastroesophageal reflux disease (GERD).</li> <li>up to 6 months to reduce the risk of stomach ulcers in some people taking pain medicines called non-steroidal anti-inflammatory drugs (NSAIDs).</li> <li>treating patients with a stomach infection (<span class="Italics">Helicobacter pylori</span>) and a stomach ulcer, along with the antibiotics amoxicillin and clarithromycin.</li> <li>the long-term treatment of conditions where your stomach makes too much acid, including Zollinger-Ellison Syndrome. Zollinger-Ellison Syndrome is a rare condition in which the stomach produces a more than normal amount of acid.</li> </ul>Esomeprazole magnesium for delayed-release oral suspension is used in children and adolescents 12 to 17 years of age for:<br/> <ul> <li>4 to 8 weeks to heal EE.</li> <li>4 weeks to treat heartburn and other symptoms that happen with GERD.</li> </ul>Esomeprazole magnesium for delayed-release oral suspension is used in children 1 to 11 years of age for:<br/> <ul> <li>8 weeks to heal EE.</li> <li>up to 8 weeks to treat heartburn and other symptoms that happen with GERD.</li> </ul>Esomeprazole magnesium delayed-release oral suspension is used in children 1 month to less than 1 year of age to treat GERD with EE for up to 6 weeks.<br/>It is not known if esomeprazole magnesium is safe and effective in children under 1 month of age for the treatment of GERD with EE.<br/>It is not known if esomeprazole magnesium is safe and effective in children less than 1 year of age for the treatment of GERD symptoms.<br/>It is not known if esomeprazole magnesium is safe and effective in children to reduce the risk of stomach ulcers in children who take medicines called NSAIDs, to treat <span class="Italics">Helicobacter pylori</span> stomach infection to lower the risk of a stomach ulcer returning, and to treat conditions where your stomach makes too much acid.</td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold">Do not take esomeprazole magnesium for delayed-release oral suspension if you are:</span> <br/> <ul> <li>allergic to esomeprazole magnesium, any other PPI medicine, or any of the ingredients in esomeprazole magnesium for delayed-release oral suspension. See the end of this Medication Guide for a complete list of ingredients in esomeprazole magnesium for delayed-release oral suspension.</li> </ul> <p class="First">Tell your doctor right away or get emergency medical help if you get any of the following symptoms of an allergic reaction with esomeprazole magnesium:</p> <p>      ο rash                        o throat tightness</p> <p>      o face swelling            o difficulty breathing</p> <p>taking a medicine that contains rilpivirine (EDURANT, COMPLERA, ODEFSEY) used to treat HIV-1 (Human Immunodeficiency Virus).</p> </td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold">Before taking esomeprazole magnesium for delayed-release oral suspension, tell your doctor about all of your medical conditions, including if you:</span> <br/> <ul> <li>have low magnesium levels, low calcium levels and low potassium levels in your blood.</li> <li>have liver problems.</li> <li>are pregnant or plan to become pregnant. It is not known if esomeprazole magnesium for delayed-release oral suspension will harm your unborn baby.</li> <li>are breastfeeding or planning to breastfeed. Esomeprazole magnesium may pass into your breast milk. Talk to your doctor about the best way to feed your baby if you take esomeprazole magnesium for delayed-release oral suspension.</li> </ul> <span class="Bold">Tell your doctor about all of the medicines you take</span>, including prescription and over-the-counter medicines, vitamins, and herbal supplements.<br/> <span class="Bold">Especially tell your doctor if you take:</span> clopidogrel (Plavix), methotrexate (Otrxup, Rasuvo, Trexall, XATMEP), digoxin (LANOXIN), rilpivirine (EDURANT), St. John’s Wort (Hypericum perforatum), or rifampin (Rimactane, Rifater, Rifamate).</td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold">How should I take esomeprazole magnesium for delayed-release oral suspension?</span> <br/> <ul> <li>Take esomeprazole magnesium for delayed-release oral suspension exactly as prescribed by your doctor.</li> <li>Do not change your dose or stop esomeprazole magnesium for delayed-release oral suspension without talking to your doctor.</li> <li>Take esomeprazole magnesium for delayed-release oral suspension at least 1 hour before a meal.</li> <li>Antacids may be taken with esomeprazole magnesium for delayed-release oral suspension.</li> <li>If you forget to take a dose of esomeprazole magnesium for delayed-release oral suspension, take it as soon as you remember. If it is almost time for your next dose, do not take the missed dose. Take the next dose on time. Do not take a double dose to make up for a missed dose.</li> <li>If you take too much esomeprazole magnesium for delayed-release oral suspension, call your doctor or local poison control center right away at 1-800-222-1222, or go to the nearest hospital emergency room.</li> <li>See the <span class="Bold">Instructions for Use</span> at the end of this Medication Guide for instructions how to take esomeprazole magnesium for delayed-release oral suspension, and how to mix and give esomeprazole magnesium for delayed-release oral suspension through a nasogastric tube or gastric tube.</li> </ul> </td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold">What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension?</span> <br/> <span class="Bold">Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including:</span> <br/> <ul> <li> <span class="Bold">See</span><span class="Bold">“What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension?”</span> </li> <li> <span class="Bold">Low vitamin B-12 levels in your body</span> can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for a long time (more than 3 years). Tell your doctor if you have symptoms of low vitamin B-12 levels, including shortness of breath, lightheadedness, irregular heartbeat, muscle weakness, pale skin, feeling tired, mood changes, and tingling or numbness in the arms and legs.</li> <li> <span class="Bold">Low magnesium levels in your body</span> can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for at least 3 months. Tell your doctor right away if you have symptoms of low magnesium levels, including seizures, dizziness, irregular heartbeat, jitteriness, muscle aches or weakness, and spasms of hands, feet or voice.</li> <li> <span class="Bold">Stomach growths (fundic gland polyps).</span> People who take PPI medicines for a long time have an increased risk of developing a certain type of stomach growths called fundic gland polyps, especially after taking PPI medicines for more than 1 year.</li> <li> <span class="Bold">Severe skin reactions.</span> Esomeprazole magnesium for delayed-release oral suspension can cause rare but severe skin reactions that may affect any part of your body. These serious skin reactions may need to be treated in a hospital and may be life threatening:</li> </ul> <p class="First">         • Skin rash which may have blistering, peeling or bleeding on any part of your skin (including your lips, eyes, mouth, nose, genitals, hands or feet).<br/>         • You may also have fever, chills, body aches, shortness of breath, or enlarged lymph nodes.</p> <p>Stop taking esomeprazole magnesium for delayed-release oral suspension and call your doctor right away. These symptoms may be the first sign of a severe skin reaction.<br/>The most common side effects of esomeprazole magnesium for delayed-release oral suspension include:</p> <p>      • headache            • stomach (abdominal) pain</p> <p>      • diarrhea              • constipation</p> <p>      • nausea                • dry mouth</p> <p>      • gas</p> <p>These are not all the possible side effects of esomeprazole magnesium for delayed-release oral suspension.<br/>Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.</p> </td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold">How should I store esomeprazole magnesium for delayed-release oral suspension?</span> <br/> <ul> <li>Store esomeprazole magnesium for delayed-release oral suspension at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). [See USP Controlled Room Temperature].</li> </ul> <span class="Bold">Keep esomeprazole magnesium for delayed-release oral suspension and all medicines out of the reach of children.</span></td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold">General information about the safe and effective use of esomeprazole magnesium for delayed-release oral suspension.</span> <br/>Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use esomeprazole magnesium for delayed-release oral suspension for a condition for which it was not prescribed. Do not give esomeprazole magnesium for delayed-release oral suspension to other people, even if they have the same symptoms you have. It may harm them.<br/>You can ask your pharmacist or doctor for information about esomeprazole magnesium for delayed-release oral suspension that is written for health professionals.</td> </tr> <tr> <td class="Botrule Lrule Rrule Toprule"><span class="Bold">What are the ingredients in esomeprazole magnesium for delayed-release oral suspension?</span> <br/> <span class="Bold">Active ingredient:</span> esomeprazole magnesium USP<br/> <span class="Bold">Inactive ingredients in esomeprazole magnesium for delayed-release oral suspension:</span> <br/>The inactive granules are composed of the following ingredients: citric acid monohydrate, colloidal silicon dioxide, crospovidone, dextrose monohydrate, ferric oxide yellow, hydroxy propyl cellulose and xanthan gum.<br/>Esomeprazole 2.5 mg, 5 mg, 20 mg, and 40 mg pellets contain following ingredients: ethyl cellulose, magnesium oxide (light), magnesium stearate, methacrylic acid and ethyl acrylate copolymer dispersion, mono and diglycerides, polysorbate 80, povidone, sugar spheres 60-80 mesh, talc and triethyl citrate.</td> </tr> <tr class="Last"> <td class="Botrule Lrule Rrule Toprule"> <p class="First"> <span class="Bold">Instructions for Use</span> <br/> <span class="Bold">Esomeprazole Magnesium </span> </p> <p> <span class="Bold">(es-ho-MEP-ra-zole mag-NEE-zee-um)</span> <br/> <span class="Bold">for Delayed-Release Oral Suspension</span> </p> <p> <br/> <span class="Bold">Taking Esomeprazole Magnesium for Delayed-Release Oral Suspension in water:</span> </p> <ul> <li>Esomeprazole Magnesium for delayed-release oral suspension comes in foil packets containing 2.5 mg, 5 mg, 20 mg, or 40 mg of esomeprazole magnesium.</li> <li>Use an oral syringe to measure the amount of water needed to mix your dose. Ask your pharmacist for an oral syringe.</li> <li>If your prescribed dose is 2.5 mg or 5 mg, add 5 mL of water to a container. Add the contents of a foil packet containing the dose prescribed by your doctor.</li> <li>If your prescribed dose is 20 mg or 40 mg, add 15 mL of water to a container. Add the contents of a foil packet containing the dose prescribed by your doctor.</li> <li>If you or your child are instructed to use more than one foil packet for the prescribed dose, follow the mixing instructions provided by your pharmacist or doctor.</li> <li>Stir.</li> <li>Leave the mixture for 2 to 3 minutes to thicken.</li> <li>Stir and drink the mixture within 30 minutes. If not used within 30 minutes, throw away this dose and mix a new dose.</li> <li>If any medicine remains in the container after drinking, add more water, stir, and drink right away.</li> <li>For young children, you can give the dose with an oral syringe. Rinse the oral syringe with water after each use.</li> </ul> <p> <span class="Bold">Giving Esomeprazole Magnesium for Delayed-Release Oral Suspension with water through a nasogastric tube (NG tube) or gastric tube</span> </p> <p> <br/>Esomeprazole Magnesium for delayed-release oral suspension:</p> <ul> <li>Esomeprazole Magnesium for delayed-release oral suspension comes in foil packets containing 2.5 mg, 5 mg, 20 mg, or 40 mg of esomeprazole magnesium.</li> <li>Use only a catheter tipped syringe to give esomeprazole magnesium for delayed-release oral suspension through a NG tube or gastric tube.</li> <li>If your prescribed dose is 2.5 mg or 5 mg, add 5 mL of water to a catheter tipped syringe.Add the contents of a foil packet containing the dose prescribed by your doctor.</li> <li>If your prescribed dose is 20 mg, or 40 mg, add 15 mL of water to a catheter tipped syringe.Add the contents of a foil packet containing the dose prescribed by your doctor.</li> <li>Shake the syringe well for 15 seconds and then leave it for 2 to 3 minutes to thicken.</li> <li>Shake the syringe and give the medicine through the NG or gastric tube (French size 6 or larger) into the stomach within 30 minutes.</li> <li>Refill the syringe with the same amount of water (either 5 mL or 15 mL of water depending on your dose).</li> <li>Shake the syringe and flush any remaining medicine from the NG tube or gastric tube into the stomach.</li> </ul> <p>This Instructions for Use has been approved by the U.S. Food and Drug Administration.</p> <p></p> <p>Trademarks are the property of their respective owners.</p> <p></p> <p>For more information, call 1-800-912-9561.</p> <p></p> <p> <img alt="Image" src="/dailymed/image.cfm?name=logo-2.jpg&amp;setid=992b1830-55cc-4e95-8d6d-e7f796d5b373"/></p> <p> <span class="Bold">Manufactured by:</span> <br/>TORRENT PHARMACEUTICALS LTD., INDIA.</p> <p> <span class="Bold">Manufactured for:</span> <br/>TORRENT PHARMA INC., Basking Ridge, NJ 07920.</p> <p></p> <p>8070607                        Revised: September 2024</p> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"100%\">\n<caption>\n<span></span>\n</caption>\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td class=\"Botrule Lrule Rrule Toprule\">\n<p class=\"First\">\n<span class=\"Bold\">MEDICATION GUIDE</span>\n</p>\n<p></p>\n<p>\n<span class=\"Bold\">Esomeprazole Magnesium (es-ho-MEP-ra-zole mag-NEE-zee-um) </span>\n</p>\n<p>\n<span class=\"Bold\">for Delayed-Release Oral Suspension</span>\n</p>\n</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\">\n<p class=\"First\">\n<span class=\"Bold\">What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension?</span>\n<br/>\n<span class=\"Bold\">Esomeprazole magnesium for delayed-release oral suspension may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor.</span>\n<br/>\n<span class=\"Bold\">Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including:</span>\n</p>\n<ul>\n<li>\n<span class=\"Bold\">A type of kidney problem (acute tubulointerstitial nephritis). </span>Some people who take proton pump inhibitor (PPI) medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop a kidney problem called acute tubulointerstitial nephritis that can happen at any time during treatment with esomeprazole magnesium for delayed-release oral suspension. Call your doctor right away if you have a decrease in the amount that you urinate or if you have blood in your urine.</li>\n<li>\n<span class=\"Bold\">Diarrhea caused by an infection (<span class=\"Italics\">Clostridium difficile</span>) in your intestines. </span>Call your doctor right away if you have watery stools or stomach pain that does not go away. You may or may not have a fever.</li>\n<li>\n<span class=\"Bold\">Bone fractures (hip, wrist, or spine). </span>Bone fractures in the hip, wrist, or spine may happen in people who take multiple daily doses of PPI medicines and for a long period of time (a year or longer). Tell your doctor if you have a bone fracture, especially in the hip, wrist, or spine.</li>\n<li>\n<span class=\"Bold\">Certain types of lupus erythematosus. </span>Lupus erythematosus is an autoimmune disorder (the body’s immune cells attack other cells or organs in the body). Some people who take PPI medicines, including esomeprazole magnesium for delayed-release oral suspension, may develop certain types of lupus erythematosus or have worsening of the lupus they already have. Call your doctor right away if you have new or worsening joint pain or a rash on your cheeks or arms that gets worse in the sun.</li>\n</ul>\n<p>Talk to your doctor about your risk of these serious side effects.</p>\n<p>Esomeprazole magnesium for delayed-release oral suspension can have other serious side effects. See <span class=\"Bold\">“What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension?”</span>\n</p>\n</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\">\n<p class=\"First\">\n<span class=\"Bold\">What is esomeprazole magnesium for delayed-release oral suspension?</span>\n</p>\n<p>A prescription medicine called a proton pump inhibitor (PPI) used to reduce the amount of acid in your stomach.<br/>Esomeprazole magnesium delayed-release oral suspension is used in adults for:</p>\n<ul>\n<li>4 to 8 weeks for the healing and symptom relief of acid-related damage to the esophagus (erosive esophagitis or EE). Your doctor may prescribe another 4 to 8 weeks of esomeprazole magnesium for delayed-release oral suspension in patients whose EE does not heal.</li>\n<li>maintaining healing of EE.</li>\n<li>4 to 8 weeks to treat heartburn and other symptoms that happen with gastroesophageal reflux disease (GERD).</li>\n<li>up to 6 months to reduce the risk of stomach ulcers in some people taking pain medicines called non-steroidal anti-inflammatory drugs (NSAIDs).</li>\n<li>treating patients with a stomach infection (<span class=\"Italics\">Helicobacter pylori</span>) and a stomach ulcer, along with the antibiotics amoxicillin and clarithromycin.</li>\n<li>the long-term treatment of conditions where your stomach makes too much acid, including Zollinger-Ellison Syndrome. Zollinger-Ellison Syndrome is a rare condition in which the stomach produces a more than normal amount of acid.</li>\n</ul>Esomeprazole magnesium for delayed-release oral suspension is used in children and adolescents 12 to 17 years of age for:<br/>\n<ul>\n<li>4 to 8 weeks to heal EE.</li>\n<li>4 weeks to treat heartburn and other symptoms that happen with GERD.</li>\n</ul>Esomeprazole magnesium for delayed-release oral suspension is used in children 1 to 11 years of age for:<br/>\n<ul>\n<li>8 weeks to heal EE.</li>\n<li>up to 8 weeks to treat heartburn and other symptoms that happen with GERD.</li>\n</ul>Esomeprazole magnesium delayed-release oral suspension is used in children 1 month to less than 1 year of age to treat GERD with EE for up to 6 weeks.<br/>It is not known if esomeprazole magnesium is safe and effective in children under 1 month of age for the treatment of GERD with EE.<br/>It is not known if esomeprazole magnesium is safe and effective in children less than 1 year of age for the treatment of GERD symptoms.<br/>It is not known if esomeprazole magnesium is safe and effective in children to reduce the risk of stomach ulcers in children who take medicines called NSAIDs, to treat <span class=\"Italics\">Helicobacter pylori</span> stomach infection to lower the risk of a stomach ulcer returning, and to treat conditions where your stomach makes too much acid.</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\">Do not take esomeprazole magnesium for delayed-release oral suspension if you are:</span>\n<br/>\n<ul>\n<li>allergic to esomeprazole magnesium, any other PPI medicine, or any of the ingredients in esomeprazole magnesium for delayed-release oral suspension. See the end of this Medication Guide for a complete list of ingredients in esomeprazole magnesium for delayed-release oral suspension.</li>\n</ul>\n<p class=\"First\">Tell your doctor right away or get emergency medical help if you get any of the following symptoms of an allergic reaction with esomeprazole magnesium:</p>\n<p>      ο rash                        o throat tightness</p>\n<p>      o face swelling            o difficulty breathing</p>\n<p>taking a medicine that contains rilpivirine (EDURANT, COMPLERA, ODEFSEY) used to treat HIV-1 (Human Immunodeficiency Virus).</p>\n</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\">Before taking esomeprazole magnesium for delayed-release oral suspension, tell your doctor about all of your medical conditions, including if you:</span>\n<br/>\n<ul>\n<li>have low magnesium levels, low calcium levels and low potassium levels in your blood.</li>\n<li>have liver problems.</li>\n<li>are pregnant or plan to become pregnant. It is not known if esomeprazole magnesium for delayed-release oral suspension will harm your unborn baby.</li>\n<li>are breastfeeding or planning to breastfeed. Esomeprazole magnesium may pass into your breast milk. Talk to your doctor about the best way to feed your baby if you take esomeprazole magnesium for delayed-release oral suspension.</li>\n</ul>\n<span class=\"Bold\">Tell your doctor about all of the medicines you take</span>, including prescription and over-the-counter medicines, vitamins, and herbal supplements.<br/>\n<span class=\"Bold\">Especially tell your doctor if you take:</span> clopidogrel (Plavix), methotrexate (Otrxup, Rasuvo, Trexall, XATMEP), digoxin (LANOXIN), rilpivirine (EDURANT), St. John’s Wort (Hypericum perforatum), or rifampin (Rimactane, Rifater, Rifamate).</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\">How should I take esomeprazole magnesium for delayed-release oral suspension?</span>\n<br/>\n<ul>\n<li>Take esomeprazole magnesium for delayed-release oral suspension exactly as prescribed by your doctor.</li>\n<li>Do not change your dose or stop esomeprazole magnesium for delayed-release oral suspension without talking to your doctor.</li>\n<li>Take esomeprazole magnesium for delayed-release oral suspension at least 1 hour before a meal.</li>\n<li>Antacids may be taken with esomeprazole magnesium for delayed-release oral suspension.</li>\n<li>If you forget to take a dose of esomeprazole magnesium for delayed-release oral suspension, take it as soon as you remember. If it is almost time for your next dose, do not take the missed dose. Take the next dose on time. Do not take a double dose to make up for a missed dose.</li>\n<li>If you take too much esomeprazole magnesium for delayed-release oral suspension, call your doctor or local poison control center right away at 1-800-222-1222, or go to the nearest hospital emergency room.</li>\n<li>See the <span class=\"Bold\">Instructions for Use</span> at the end of this Medication Guide for instructions how to take esomeprazole magnesium for delayed-release oral suspension, and how to mix and give esomeprazole magnesium for delayed-release oral suspension through a nasogastric tube or gastric tube.</li>\n</ul>\n</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\">What are the possible side effects of esomeprazole magnesium for delayed-release oral suspension?</span>\n<br/>\n<span class=\"Bold\">Esomeprazole magnesium for delayed-release oral suspension can cause serious side effects, including:</span>\n<br/>\n<ul>\n<li>\n<span class=\"Bold\">See</span><span class=\"Bold\">“What is the most important information I should know about esomeprazole magnesium for delayed-release oral suspension?”</span>\n</li>\n<li>\n<span class=\"Bold\">Low vitamin B-12 levels in your body</span> can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for a long time (more than 3 years). Tell your doctor if you have symptoms of low vitamin B-12 levels, including shortness of breath, lightheadedness, irregular heartbeat, muscle weakness, pale skin, feeling tired, mood changes, and tingling or numbness in the arms and legs.</li>\n<li>\n<span class=\"Bold\">Low magnesium levels in your body</span> can happen in people who have taken esomeprazole magnesium for delayed-release oral suspension for at least 3 months. Tell your doctor right away if you have symptoms of low magnesium levels, including seizures, dizziness, irregular heartbeat, jitteriness, muscle aches or weakness, and spasms of hands, feet or voice.</li>\n<li>\n<span class=\"Bold\">Stomach growths (fundic gland polyps).</span> People who take PPI medicines for a long time have an increased risk of developing a certain type of stomach growths called fundic gland polyps, especially after taking PPI medicines for more than 1 year.</li>\n<li>\n<span class=\"Bold\">Severe skin reactions.</span> Esomeprazole magnesium for delayed-release oral suspension can cause rare but severe skin reactions that may affect any part of your body. These serious skin reactions may need to be treated in a hospital and may be life threatening:</li>\n</ul>\n<p class=\"First\">         • Skin rash which may have blistering, peeling or bleeding on any part of your skin (including your lips, eyes, mouth, nose, genitals, hands or feet).<br/>         • You may also have fever, chills, body aches, shortness of breath, or enlarged lymph nodes.</p>\n<p>Stop taking esomeprazole magnesium for delayed-release oral suspension and call your doctor right away. These symptoms may be the first sign of a severe skin reaction.<br/>The most common side effects of esomeprazole magnesium for delayed-release oral suspension include:</p>\n<p>      • headache            • stomach (abdominal) pain</p>\n<p>      • diarrhea              • constipation</p>\n<p>      • nausea                • dry mouth</p>\n<p>      • gas</p>\n<p>These are not all the possible side effects of esomeprazole magnesium for delayed-release oral suspension.<br/>Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.</p>\n</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\">How should I store esomeprazole magnesium for delayed-release oral suspension?</span>\n<br/>\n<ul>\n<li>Store esomeprazole magnesium for delayed-release oral suspension at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). [See USP Controlled Room Temperature].</li>\n</ul>\n<span class=\"Bold\">Keep esomeprazole magnesium for delayed-release oral suspension and all medicines out of the reach of children.</span></td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\">General information about the safe and effective use of esomeprazole magnesium for delayed-release oral suspension.</span>\n<br/>Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use esomeprazole magnesium for delayed-release oral suspension for a condition for which it was not prescribed. Do not give esomeprazole magnesium for delayed-release oral suspension to other people, even if they have the same symptoms you have. It may harm them.<br/>You can ask your pharmacist or doctor for information about esomeprazole magnesium for delayed-release oral suspension that is written for health professionals.</td>\n</tr>\n<tr>\n<td class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\">What are the ingredients in esomeprazole magnesium for delayed-release oral suspension?</span>\n<br/>\n<span class=\"Bold\">Active ingredient:</span> esomeprazole magnesium USP<br/>\n<span class=\"Bold\">Inactive ingredients in esomeprazole magnesium for delayed-release oral suspension:</span>\n<br/>The inactive granules are composed of the following ingredients: citric acid monohydrate, colloidal silicon dioxide, crospovidone, dextrose monohydrate, ferric oxide yellow, hydroxy propyl cellulose and xanthan gum.<br/>Esomeprazole 2.5 mg, 5 mg, 20 mg, and 40 mg pellets contain following ingredients: ethyl cellulose, magnesium oxide (light), magnesium stearate, methacrylic acid and ethyl acrylate copolymer dispersion, mono and diglycerides, polysorbate 80, povidone, sugar spheres 60-80 mesh, talc and triethyl citrate.</td>\n</tr>\n<tr class=\"Last\">\n<td class=\"Botrule Lrule Rrule Toprule\">\n<p class=\"First\">\n<span class=\"Bold\">Instructions for Use</span>\n<br/>\n<span class=\"Bold\">Esomeprazole Magnesium </span>\n</p>\n<p>\n<span class=\"Bold\">(es-ho-MEP-ra-zole mag-NEE-zee-um)</span>\n<br/>\n<span class=\"Bold\">for Delayed-Release Oral Suspension</span>\n</p>\n<p>\n<br/>\n<span class=\"Bold\">Taking Esomeprazole Magnesium for Delayed-Release Oral Suspension in water:</span>\n</p>\n<ul>\n<li>Esomeprazole Magnesium for delayed-release oral suspension comes in foil packets containing 2.5 mg, 5 mg, 20 mg, or 40 mg of esomeprazole magnesium.</li>\n<li>Use an oral syringe to measure the amount of water needed to mix your dose. Ask your pharmacist for an oral syringe.</li>\n<li>If your prescribed dose is 2.5 mg or 5 mg, add 5 mL of water to a container. Add the contents of a foil packet containing the dose prescribed by your doctor.</li>\n<li>If your prescribed dose is 20 mg or 40 mg, add 15 mL of water to a container. Add the contents of a foil packet containing the dose prescribed by your doctor.</li>\n<li>If you or your child are instructed to use more than one foil packet for the prescribed dose, follow the mixing instructions provided by your pharmacist or doctor.</li>\n<li>Stir.</li>\n<li>Leave the mixture for 2 to 3 minutes to thicken.</li>\n<li>Stir and drink the mixture within 30 minutes. If not used within 30 minutes, throw away this dose and mix a new dose.</li>\n<li>If any medicine remains in the container after drinking, add more water, stir, and drink right away.</li>\n<li>For young children, you can give the dose with an oral syringe. Rinse the oral syringe with water after each use.</li>\n</ul>\n<p>\n<span class=\"Bold\">Giving Esomeprazole Magnesium for Delayed-Release Oral Suspension with water through a nasogastric tube (NG tube) or gastric tube</span>\n</p>\n<p>\n<br/>Esomeprazole Magnesium for delayed-release oral suspension:</p>\n<ul>\n<li>Esomeprazole Magnesium for delayed-release oral suspension comes in foil packets containing 2.5 mg, 5 mg, 20 mg, or 40 mg of esomeprazole magnesium.</li>\n<li>Use only a catheter tipped syringe to give esomeprazole magnesium for delayed-release oral suspension through a NG tube or gastric tube.</li>\n<li>If your prescribed dose is 2.5 mg or 5 mg, add 5 mL of water to a catheter tipped syringe.Add the contents of a foil packet containing the dose prescribed by your doctor.</li>\n<li>If your prescribed dose is 20 mg, or 40 mg, add 15 mL of water to a catheter tipped syringe.Add the contents of a foil packet containing the dose prescribed by your doctor.</li>\n<li>Shake the syringe well for 15 seconds and then leave it for 2 to 3 minutes to thicken.</li>\n<li>Shake the syringe and give the medicine through the NG or gastric tube (French size 6 or larger) into the stomach within 30 minutes.</li>\n<li>Refill the syringe with the same amount of water (either 5 mL or 15 mL of water depending on your dose).</li>\n<li>Shake the syringe and flush any remaining medicine from the NG tube or gastric tube into the stomach.</li>\n</ul>\n<p>This Instructions for Use has been approved by the U.S. Food and Drug Administration.</p>\n<p></p>\n<p>Trademarks are the property of their respective owners.</p>\n<p></p>\n<p>For more information, call 1-800-912-9561.</p>\n<p></p>\n<p>\n<img alt=\"Image\" src=\"/dailymed/image.cfm?name=logo-2.jpg&amp;setid=992b1830-55cc-4e95-8d6d-e7f796d5b373\"/></p>\n<p>\n<span class=\"Bold\">Manufactured by:</span>\n<br/>TORRENT PHARMACEUTICALS LTD., INDIA.</p>\n<p>\n<span class=\"Bold\">Manufactured for:</span>\n<br/>TORRENT PHARMA INC., Basking Ridge, NJ 07920.</p>\n<p></p>\n<p>8070607                        Revised: September 2024</p>\n</td>\n</tr>\n</tbody>\n</table></div>" }

This Medication Guide has been approved by the U.S. Food and Drug Administration.

{ "type": "p", "children": [], "text": "This Medication Guide has been approved by the U.S. Food and Drug Administration." }

ESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 2.5 mg

{ "type": "p", "children": [], "text": "\nESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 2.5 mg" }

ESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 5  mg

{ "type": "p", "children": [], "text": "ESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 5  mg" }

ESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 20 mg

{ "type": "p", "children": [], "text": "ESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 20 mg" }

ESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 40 mg

{ "type": "p", "children": [], "text": "ESOMEPRAZOLE MAGNESIUM FOR DELAYED-RELEASE ORAL SUSPENSION 40 mg" }

Esomeprazole sodium for injection is indicated for the short-term treatment of GERD with EE in adults and pediatric patients 1 month to 17 years, inclusively as an alternative to oral therapy when oral esomeprazole is not possible or appropriate.

Esomeprazole sodium for injection is indicated for risk reduction of rebleeding of gastric or duodenal ulcers following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers in adults.

Adult Patients

The recommended adult dosage is either 20 mg or 40 mg esomeprazole sodium for injection given once daily by intravenous injection (over at least 3 minutes) or intravenous infusion (10 minutes to 30 minutes) for up to 10 days [see Dosage and Administration (2.4)].

Pediatric Patients

The recommended dosage for pediatric patients is based on age and body weight as shown in Table 1 below. Administer as an intravenous infusion over 10 to 30 minutes once daily for up to 10 days [see Dosage and Administration (2.4)].

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 1: Recommended Pediatric Dosage Regimen for GERD with EE    </span> </caption> <colgroup> <col width="25%"/> <col width="25%"/> <col width="50%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Age and Body Weight</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Dosage Regimen</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle">1 month to less than 1 year of age<br/> </td><td align="center" class="Rrule" valign="middle">0.5 mg/kg once daily<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" rowspan="2" valign="top">1 year to 17 years<br/> </td><td class="Rrule" valign="middle">less than 55 kg<br/> </td><td align="center" class="Rrule" valign="middle">10 mg once daily<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">55 kg or greater<br/> </td><td align="center" class="Rrule" valign="middle">20 mg once daily<br/> </td> </tr> </tbody> </table></div>

Completion of Treatment

The recommended adult dosage is 80 mg esomeprazole sodium for injection administered as an intravenous infusion over 30 minutes followed by a continuous infusion of 8 mg/hour for a total treatment duration of 72 hours (i.e., includes initial 30-minute loading dose plus 71.5 hours of continuous infusion) [see Dosage and Administration (2.5)]. Intravenous therapy is aimed solely at the acute initial management of bleeding gastric or duodenal ulcers and does not constitute full treatment. Administer oral acid-suppressive therapy following intravenous therapy for a full course of treatment.

GERD with EE For patients with severe hepatic impairment (Child-Pugh Class C), the maximum dosage is 20 mg once daily [see Use in Specific Populations (8.6)]. Risk Reduction of Rebleeding of Gastric or Duodenal Ulcers following Therapeutic Endoscopy in Adults For patients with mild to moderate hepatic impairment (Child-Pugh Classes A and B, respectively), administered 80 mg as an intravenous infusion over 30 minutes, followed by a continuous infusion of 6 mg/hour for 71.5 hours. For patients with severe hepatic impairment (Child-Pugh Class C), administered 80 mg as an intravenous infusion over 30 minutes, followed by a continuous infusion of 4 mg/hour for 71.5 hours [see Use in Specific Populations (8.6)].

Do not administer esomeprazole sodium for injection concomitantly with any other medications through the same intravenous site and/or tubing. Oral antacids may be used during treatment with esomeprazole sodium for injection. Intravenous Injection Over At Least 3 Minutes in Adult Patients

Intravenous Infusion Over 10 Minutes to 30 Minutes in Adult and Pediatric Patients

Storage Store the final (diluted) esomeprazole sodium for injection solution at room temperature up to 30°C (86°F) and administer within the designated time period as listed in Table 2 below.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 2: Storage Time for Final (diluted) Esomeprazole Sodium for Injection Solution      </span> </caption> <colgroup> <col width="64.14%"/> <col width="35.86%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle"><span class="Bold">Diluent</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Administer within:</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">0.9% Sodium Chloride Injection, USP<br/> </td><td align="center" class="Rrule" valign="middle">12 hours<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Lactated Ringer’s Injection, USP<br/> </td><td align="center" class="Rrule" valign="middle">12 hours<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">5% Dextrose Injection, USP<br/> </td><td align="center" class="Rrule" valign="middle">6 hours<br/> </td> </tr> </tbody> </table></div>

Do not administer esomeprazole sodium for injection concomitantly with any other medications through the same intravenous site and/or tubing. Oral antacids may be used during treatment with esomeprazole sodium for injection. Loading Dose (80 mg)

Continuous Infusion

Storage

For Injection: 40 mg of esomeprazole as a sterile, freeze-dried, white to off-white, porous cake or lyophilized powder in a single-dose vial for reconstitution.

{ "type": "p", "children": [], "text": "For Injection: 40 mg of esomeprazole as a sterile, freeze-dried, white to off-white, porous cake or lyophilized powder in a single-dose vial for reconstitution." }

{ "type": "ul", "children": [ "Esomeprazole sodium for injection is contraindicated in patients with known hypersensitivity to substituted benzimidazoles or to any component of the formulation. Hypersensitivity reactions may include anaphylaxis, anaphylactic shock, angioedema, bronchospasm, acute tubulointerstitial nephritis, and urticaria [see Warnings and Precautions (5.2), Adverse Reactions (6.2)].\n", "Proton pump inhibitors (PPIs), including esomeprazole sodium for injection, are contraindicated in patients receiving rilpivirine-containing products [see Drug Interactions (7)].\n" ], "text": "" }

In adults, symptomatic response to therapy with esomeprazole sodium for injection does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have suboptimal response or an early symptomatic relapse after completing treatment with a PPI. In older patients also consider an endoscopy.

Acute tubulointerstitial nephritis (TIN) has been observed in patients taking PPIs and may occur at any point during PPI therapy. Patients may present with varying signs and symptoms from symptomatic hypersensitivity reactions to non-specific symptoms of decreased renal function (e.g., malaise, nausea, anorexia). In reported case series, some patients were diagnosed on biopsy and in the absence of extra-renal manifestations (e.g., fever, rash or arthralgia). Discontinue esomeprazole sodium for injection and evaluate patients with suspected acute TIN [see Contraindications (4)].

Published observational studies suggest that PPI therapy like esomeprazole sodium for injection may be associated with an increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve [see Adverse Reactions (6.2)]. Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

Several published observational studies suggest that proton pump inhibitor (PPI) therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines [see Dosage and Administration (2.1, 2.2), Adverse Reactions (6.2)].

Severe cutaneous adverse reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) have been reported in association with the use of PPIs [see Adverse Reactions (6.2)]. Discontinue esomeprazole sodium for injection at the first signs or symptoms of severe cutaneous adverse reactions or other signs of hypersensitivity and consider further evaluation.

Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE) have been reported in patients taking PPIs, including esomeprazole. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematosus cases were CLE. The most common form of CLE reported in patients treated with PPIs was subacute CLE (SCLE) and occurred within weeks to years after continuous drug therapy in patients ranging from infants to the elderly. Generally, histological findings were observed without organ involvement. Systemic lupus erythematosus (SLE) is less commonly reported than CLE in patients receiving PPIs. PPI associated SLE is usually milder than non-drug induced SLE. Onset of SLE typically occurred within days to years after initiating treatment primarily in patients ranging from young adults to the elderly. The majority of patients presented with rash; however, arthralgia and cytopenia were also reported. Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving esomeprazole sodium for injection, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks. Serological testing (e.g., ANA) may be positive and elevated serological test results may take longer to resolve than clinical manifestations.

Avoid concomitant use of esomeprazole sodium for injection with clopidogrel. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as esomeprazole, that inhibit CYP2C19 activity. Concomitant use of clopidogrel with 40 mg esomeprazole reduces the pharmacological activity of clopidogrel. When using esomeprazole sodium for injection consider alternative anti-platelet therapy [see Drug Interactions (7)].

Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. Hypomagnesemia may lead to hypocalcemia and/or hypokalemia and may exacerbate underlying hypocalcemia in at-risk patients. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI. For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically [see Adverse Reactions (6.2)]. Consider monitoring magnesium and calcium levels prior to initiation of esomeprazole sodium for injection and periodically while on treatment in patients with a preexisting risk of hypocalcemia (e.g., hypoparathyroidism). Supplement with magnesium and/or calcium, as necessary. If hypocalcemia is refractory to treatment, consider discontinuing the PPI.

Drugs which induce CYP2C19 or CYP3A4 (such as St. John’s Wort or rifampin) can substantially decrease esomeprazole concentrations [see Drug Interactions (7)]. Avoid concomitant use of esomeprazole sodium for injection with St. John’s Wort or rifampin.

Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors. Healthcare providers should temporarily stop esomeprazole treatment at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g., for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary [see Drug Interactions (7)].

Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration, a temporary withdrawal of the PPI may be considered in some patients [see Drug Interactions (7)].

PPI use is associated with an increased risk of fundic gland polyps that increases with long-term use, especially beyond one year. Most PPI users who developed fundic gland polyps were asymptomatic and fundic gland polyps were identified incidentally on endoscopy. Use the shortest duration of PPI therapy appropriate to the condition being treated.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Symptomatic GERD and EE Adults The safety of esomeprazole sodium for injection is based on results from clinical trials conducted in four different populations including healthy subjects (n=204) and patients with bleeding gastric or duodenal ulcers (n=375). The data described below reflect exposure to esomeprazole sodium for injection in 359 patients in actively-controlled trials: symptomatic GERD with or without a history of EE (n=199) and patients with EE (n=160). The population was 18 to 77 years of age; 45% Male, 52% Caucasian, 17% Black, 3% Asian, and 28% other race. Most patients received doses of either 20 or 40 mg either as an infusion or an injection. Adverse reactions occurring in at least 1% of patients are listed below in Table 3:

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 3: Adverse Reactions<span class="Sup">1</span> in the Esomeprazole Sodium for Injection Group in Active Controlled Trials of Symptomatic GERD with or without EE      </span> </caption> <colgroup> <col width="50%"/> <col width="50%"/> </colgroup> <tfoot> <tr class="First Last"> <td colspan="22"><span class="Sup">1</span> Incidence of at least 1% in the Esomeprazole sodium for injection group     </td> </tr> </tfoot> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" valign="middle"><span class="Bold">Adverse Reactions</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">% of patients</span> <br/> <span class="Bold">Esomeprazole sodium for injection</span> <br/> <span class="Bold">(n=359)</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Headache<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="middle">11<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Flatulence<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="middle">10<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Nausea<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="middle">6<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Abdominal pain<br/> </td><td align="center" class="Rrule" valign="middle">6<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Diarrhea <br/> </td><td align="center" class="Rrule" valign="middle">4<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Mouth dry<br/> </td><td align="center" class="Rrule" valign="middle">4<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Dizziness/vertigo<br/> </td><td align="center" class="Rrule" valign="middle">3<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Constipation<br/> </td><td align="center" class="Rrule" valign="middle">3<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle">Injection site reaction<br/> </td><td align="center" class="Rrule" valign="middle">2<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">Pruritus<br/> </td><td align="center" class="Rrule" valign="middle">1<br/> </td> </tr> </tbody> </table></div>

Intravenous treatment with esomeprazole sodium for injection 20 and 40 mg-administered as an injection or as an infusion was found to have a safety profile similar to that of oral esomeprazole. Pediatrics A randomized, open-label, multi-national study to evaluate the pharmacokinetics of repeated intravenous doses of once daily esomeprazole sodium for injection in pediatric patients 1 month to 17 years old, inclusive was performed [see Clinical Pharmacology (12.3)]. The safety results are consistent with the known safety profile of esomeprazole and no unexpected safety signals were identified. Risk Reduction of Rebleeding of Gastric or Duodenal Ulcers in Adults The data described in Table 4 below reflect exposure to esomeprazole sodium for injection in 375 patients who presented with endoscopically confirmed gastric or duodenal ulcer bleeding in a placebo-controlled trial. The population was 18 to 98 years old; 68% Male, 87% Caucasian, 1% Black, 7% Asian, and 4% other race. Following endoscopic hemostasis, patients received either placebo or 80 mg esomeprazole sodium for injection as an intravenous infusion over 30 minutes followed by a continuous infusion of 8 mg/hour for a total treatment duration of 72 hours. After the initial 72-hour period, all patients received an oral PPI for 27 days.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 4: Adverse Reactions<span class="Sup">1</span> Occurring within 72 Hours after Start of Treatment in Patients with Endoscopically Confirmed Bleeding Ulcers     </span> </caption> <colgroup> <col width="33.34%"/> <col width="33.34%"/> <col width="33.34%"/> </colgroup> <tfoot> <tr class="First Last"> <td colspan="20"><span class="Sup">1.</span> Incidence ≥1% in the esomeprazole sodium for injection group and greater than placebo group<br/> <span class="Sup">2.</span> Injection site reactions included erythema, swelling, inflammation, pruritus, phlebitis, thrombophlebitis and superficial phlebitis.      </td> </tr> </tfoot> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle"></td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">% of patients</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Esomeprazole sodium for injection</span> <br/> <span class="Bold">(n=375) </span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold">Placebo</span> <br/> <span class="Bold">(n=389) </span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Duodenal ulcer hemorrhage <br/> </td><td align="center" class="Rrule" valign="top">4<br/> </td><td align="center" class="Rrule" valign="top">4<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Injection site reaction<span class="Italics"><span class="Sup">2</span></span> <br/> </td><td align="center" class="Rrule" valign="top">4<br/> </td><td align="center" class="Rrule" valign="top">1<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Pyrexia <br/> </td><td align="center" class="Rrule" valign="top">4<br/> </td><td align="center" class="Rrule" valign="top">3<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">Cough <br/> </td><td align="center" class="Rrule" valign="top">1<br/> </td><td align="center" class="Rrule" valign="top">0.3<br/> </td> </tr> <tr class="Last"> <td align="justify" class="Lrule Rrule" valign="top">Dizziness <br/> </td><td align="center" class="Rrule" valign="top">1<br/> </td><td align="center" class="Rrule" valign="top">1<br/> </td> </tr> </tbody> </table></div>

With the exception of injection site reactions described above, intravenous treatment with esomeprazole sodium for injection administered as an injection or as an infusion was found to have a safety profile similar to that of oral esomeprazole.

The following adverse reactions have been identified during post-approval use of esomeprazole. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Blood and Lymphatic System Disorders: agranulocytosis, pancytopenia; Eye Disorders: blurred vision; Gastrointestinal Disorders: pancreatitis; stomatitis; microscopic colitis; fundic gland polyps; Hepatobiliary Disorders: hepatic failure, hepatitis with or without jaundice; Immune System Disorders: anaphylactic reaction/shock; systemic lupus erythematosus; Infections and Infestations: GI candidiasis; Metabolism and nutritional disorders: hypomagnesemia (may lead to hypocalcemia and/or hypokalemia) [see Warnings and Precautions (5.8)], hyponatremia; Musculoskeletal and Connective Tissue Disorders: muscular weakness, myalgia, bone fracture; Nervous System Disorders: hepatic encephalopathy, taste disturbance; Psychiatric Disorders: aggression, agitation, depression, hallucination; Renal and Urinary Disorders: interstitial nephritis; Reproductive System and Breast Disorders: gynecomastia, erectile dysfunction; Respiratory, Thoracic and Mediastinal Disorders: bronchospasm; Skin and Subcutaneous Tissue Disorders: alopecia, erythema multiforme, hyperhidrosis, photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN, some fatal), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP), cutaneous lupus erythematosus. Adverse reactions associated with omeprazole may also be expected to occur with esomeprazole sodium for injection. See the full prescribing information for oral omeprazole for complete safety information.

Tables 5 and 6 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them. Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs.

{ "type": "p", "children": [], "text": "Tables 5 and 6 include drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with esomeprazole and instructions for preventing or managing them.\n Consult the labeling of concomitantly used drugs to obtain further information about interactions with PPIs." }

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 5: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics       </span> </caption> <colgroup> <col width="23.36%"/> <col width="76.64%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Antiretrovirals</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known.<br/> <ul class="Disc"> <li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> </li> </ul> <ul class="Disc"> <li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> </li> </ul> <ul class="Disc"> <li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole.</li> </ul> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics">Intervention:</span> <br/> </td><td align="justify" class="Rrule" valign="top"><span class="Underline">Rilpivirine-containing products:</span> Concomitant use with esomeprazole sodium for injection is contraindicated <span class="Italics">[see <a href="#Section_4">Contraindications (4)</a>]</span>.<br/> <br/> <span class="Underline">Atazanavir:</span> See prescribing information for atazanavir for dosing information.<br/> <br/> <span class="Underline">Nelfinavir:</span> Avoid concomitant use with esomeprazole sodium for injection. See prescribing information for nelfinavir.<br/> <br/> <span class="Underline">Saquinavir:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities.<br/> <br/> <span class="Underline">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Warfarin</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="top">Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Methotrexate</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics"> <br/>Clinical Impact:</span></td><td align="justify" class="Rrule" valign="top">Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class="Italics">[see <a href="#Section_5.10">Warnings and Precautions (5.11)</a>].</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics"> <br/>Intervention:</span><span class="Italics"></span></td><td align="justify" class="Rrule" valign="top">A temporary withdrawal of esomeprazole sodium for injection may be considered in some patients receiving high-dose methotrexate.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol, diazepam)</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Clopidogrel</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> <br/>There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel<span class="Italics">.</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics">Intervention:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Avoid concomitant use with esomeprazole sodium for injection. Consider use of alternative anti-platelet therapy <span class="Italics">[see <a href="#Section_5.6">Warnings and Precautions (5.7)</a>].</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Citalopram</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Increased exposure of citalopram leading to an increased risk of QT prolongation <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="top">Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Cilostazol</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="top">Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Digoxin</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact:</span> <br/> </td><td class="Rrule" valign="top">Potential for increased exposure of digoxin <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="top">Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin.<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole)</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="middle"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="top">Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole sodium for injection and MMF. Use esomeprazole sodium for injection with caution in transplant patients receiving MMF <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>]</span>.<br/> <br/>See the prescribing information for other drugs dependent on gastric pH for absorption.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Tacrolimus</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class="Italics">.</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td class="Rrule" valign="top">Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Interactions with Investigations of Neuroendocrine Tumors</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class="Italics">[see <a href="#Section_5.9">Warnings and Precautions (5.10)</a>, <a href="#Section_12.2">Clinical Pharmacology (12.2)</a>].</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="top">Discontinue esomeprazole sodium for injection at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary.<br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" colspan="2" valign="top"><span class="Bold">Interaction with Secretin Stimulation Test</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="top">Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma.<br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="top">Discontinue esomeprazole sodium for injection 4 weeks prior to testing <span class="Italics">[see <a href="#Section_12.2">Clinical Pharmacology (12.2)</a>]</span> <br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\">\n<caption>\n<span>Table 5: Clinically Relevant Interactions Affecting Drugs Co-Administered with Esomeprazole and Interaction with Diagnostics       \n\t\t\t</span>\n</caption>\n<colgroup>\n<col width=\"23.36%\"/>\n<col width=\"76.64%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Antiretrovirals</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">The effect of PPIs on antiretroviral drugs is variable. The clinical importance and the mechanisms behind these interactions are not always known.<br/>\n<ul class=\"Disc\">\n<li>Decreased exposure of some antiretroviral drugs (e.g., rilpivirine atazanavir, and nelfinavir) when used concomitantly with esomeprazole may reduce antiviral effect and promote the development of drug resistance <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n</li>\n</ul>\n<ul class=\"Disc\">\n<li>Increased exposure of other antiretroviral drugs (e.g., saquinavir) when used concomitantly with esomeprazole may increase toxicity <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n</li>\n</ul>\n<ul class=\"Disc\">\n<li>There are other antiretroviral drugs which do not result in clinically relevant interactions with esomeprazole.</li>\n</ul>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\"><span class=\"Underline\">Rilpivirine-containing products:</span> Concomitant use with esomeprazole sodium for injection is contraindicated <span class=\"Italics\">[see <a href=\"#Section_4\">Contraindications (4)</a>]</span>.<br/> <br/>\n<span class=\"Underline\">Atazanavir:</span> See prescribing information for atazanavir for dosing information.<br/> <br/>\n<span class=\"Underline\">Nelfinavir:</span> Avoid concomitant use with esomeprazole sodium for injection. See prescribing information for nelfinavir.<br/> <br/>\n<span class=\"Underline\">Saquinavir:</span> See the prescribing information for saquinavir for monitoring of potential saquinavir-related toxicities.<br/> <br/>\n<span class=\"Underline\">Other antiretrovirals:</span> See prescribing information for specific antiretroviral drugs<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Warfarin</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Increased INR and prothrombin time in patients receiving PPIs, including esomeprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Monitor INR and prothrombin time and adjust the dose of warfarin, if needed, to maintain the target INR range.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Methotrexate</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">\n<br/>Clinical Impact:</span></td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Concomitant use of esomeprazole with methotrexate (primarily at high dose) may elevate and prolong serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. No formal drug interaction studies of high-dose methotrexate with PPIs have been conducted <span class=\"Italics\">[see <a href=\"#Section_5.10\">Warnings and Precautions (5.11)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">\n<br/>Intervention:</span><span class=\"Italics\"></span></td><td align=\"justify\" class=\"Rrule\" valign=\"top\">A temporary withdrawal of esomeprazole sodium for injection may be considered in some patients receiving high-dose methotrexate.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">2C19 Substrates (e.g., clopidogrel, citalopram, cilostazol, diazepam)</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Clopidogrel</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Concomitant use of esomeprazole 40 mg resulted in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n<br/>There are no adequate combination studies of a lower dose of esomeprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel<span class=\"Italics\">.</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Avoid concomitant use with esomeprazole sodium for injection. Consider use of alternative anti-platelet therapy <span class=\"Italics\">[see <a href=\"#Section_5.6\">Warnings and Precautions (5.7)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Citalopram</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Increased exposure of citalopram leading to an increased risk of QT prolongation <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Limit the dose of citalopram to a maximum of 20 mg per day. See prescribing information for citalopram.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Cilostazol</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Increased exposure of cilostazol and one of its active metabolites (3,4-dihydro-cilostazol) <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Consider reducing the dose of cilostazol to 50 mg twice daily. See prescribing information for cilostazol.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Digoxin</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td class=\"Rrule\" valign=\"top\">Potential for increased exposure of digoxin <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Monitor digoxin concentrations and adjust the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for digoxin.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Drugs Dependent on Gastric pH for Absorption (e.g., iron salts, erlotinib, dasatinib, nilotinib, mycophenolate mofetil, ketoconazole/itraconazole)</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Esomeprazole can reduce the absorption of other drugs due to its effect on reducing intragastric acidity<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"middle\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Mycophenolate mofetil (MMF): Co-administration of omeprazole, of which esomeprazole is an enantiomer, in healthy subjects and in transplant patients receiving MMF has been reported to reduce the exposure to the active metabolite, mycophenolic acid (MPA), possibly due to a decrease in MMF solubility at an increased gastric pH. The clinical relevance of reduced MPA exposure on organ rejection has not been established in transplant patients receiving esomeprazole sodium for injection and MMF. Use esomeprazole sodium for injection with caution in transplant patients receiving MMF <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>]</span>.<br/> <br/>See the prescribing information for other drugs dependent on gastric pH for absorption.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Tacrolimus</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Potentially increased exposure of tacrolimus, especially in transplant patients who are intermediate or poor metabolizers of CYP2C19<span class=\"Italics\">.</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td class=\"Rrule\" valign=\"top\">Monitor tacrolimus whole blood concentrations and consider reducing the dose, if needed, to maintain therapeutic drug concentrations. See prescribing information for tacrolimus.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Interactions with Investigations of Neuroendocrine Tumors</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Serum chromogranin A (CgA) levels increase secondary to PPI-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors <span class=\"Italics\">[see <a href=\"#Section_5.9\">Warnings and Precautions (5.10)</a>, <a href=\"#Section_12.2\">Clinical Pharmacology (12.2)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Discontinue esomeprazole sodium for injection at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary.<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"top\"><span class=\"Bold\">Interaction with Secretin Stimulation Test</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Hyper-response in gastrin secretion in response to secretin stimulation test, falsely suggesting gastrinoma.<br/>\n</td>\n</tr>\n<tr class=\"Last\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"top\">Discontinue esomeprazole sodium for injection 4 weeks prior to testing <span class=\"Italics\">[see <a href=\"#Section_12.2\">Clinical Pharmacology (12.2)</a>]</span>\n<br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 6: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs        </span> </caption> <colgroup> <col width="23.72%"/> <col width="76.28%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">CYP2C19 or CYP3A4 Inducers</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="middle">Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="middle"><span class="Underline">St. John’s Wort, rifampin:</span> Avoid concomitant use with esomeprazole sodium for injection <span class="Italics">[see <a href="#Section_5.8">Warnings and Precautions (5.9)</a>].</span> <br/> <span class="Underline">Ritonavir-containing products:</span> see prescribing information for specific drugs<br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" colspan="2" valign="middle"><span class="Bold">Voriconazole</span> <br/> </td> </tr> <tr class="Botrule"> <td class="Lrule Rrule" valign="top"><span class="Italics">Clinical Impact:</span> <br/> </td><td align="justify" class="Rrule" valign="middle">Increased exposure of esomeprazole <span class="Italics">[see <a href="#Section_12.3">Clinical Pharmacology (12.3)</a>].</span> <br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="top"><span class="Italics">Intervention:</span><span class="Italics"></span> <br/> </td><td align="justify" class="Rrule" valign="middle">Dose adjustment of esomeprazole sodium for injection is not normally required.<br/>See prescribing information for voriconazole.<br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\">\n<caption>\n<span>Table 6: Clinically Relevant Interactions Affecting Esomeprazole When Co-Administered with Other Drugs        \n\t\t\t</span>\n</caption>\n<colgroup>\n<col width=\"23.72%\"/>\n<col width=\"76.28%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First\">\n<td class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">CYP2C19 or CYP3A4 Inducers</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">Decreased exposure of esomeprazole when used concomitantly with strong inducers <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\"><span class=\"Underline\">St. John’s Wort, rifampin:</span> Avoid concomitant use with esomeprazole sodium for injection <span class=\"Italics\">[see <a href=\"#Section_5.8\">Warnings and Precautions (5.9)</a>].</span>\n<br/>\n<span class=\"Underline\">Ritonavir-containing products:</span> see prescribing information for specific drugs<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"justify\" class=\"Lrule Rrule\" colspan=\"2\" valign=\"middle\"><span class=\"Bold\">Voriconazole</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Clinical Impact:</span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">Increased exposure of esomeprazole <span class=\"Italics\">[see <a href=\"#Section_12.3\">Clinical Pharmacology (12.3)</a>].</span>\n<br/>\n</td>\n</tr>\n<tr class=\"Last\">\n<td class=\"Lrule Rrule\" valign=\"top\"><span class=\"Italics\">Intervention:</span><span class=\"Italics\"></span>\n<br/>\n</td><td align=\"justify\" class=\"Rrule\" valign=\"middle\">Dose adjustment of esomeprazole sodium for injection is not normally required.<br/>See prescribing information for voriconazole.<br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

Risk Summary There are no adequate and well-controlled studies with esomeprazole in pregnant women. Esomeprazole is the s-isomer of omeprazole. Available epidemiologic data fail to demonstrate an increased risk of major congenital malformations or other adverse pregnancy outcomes with first trimester omeprazole use. Reproduction studies in rats and rabbits resulted in dose-dependent embryo-lethality at omeprazole doses that were approximately 3.4 to 34 times an oral human dose of 40 mg (based on a body surface area for a 60 kg person). Teratogenicity was not observed in animal reproduction studies with administration of oral esomeprazole magnesium in rats and rabbits with doses about 68 times and 42 times, respectively, an oral human dose of 40 mg (based on a body surface area basis for a 60 kg person). Changes in bone morphology were observed in offspring of rats dosed through most of pregnancy and lactation at doses equal to or greater than approximately 34 times an oral human dose of 40 mg. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age (see Data). The estimated background risks of major birth defects and miscarriage for the indicated population are unknown. All pregnancies have a background risk of birth defect, loss or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Human Data Esomeprazole is the S-isomer of omeprazole. Four epidemiological studies compared the frequency of congenital abnormalities among infants born to women who used omeprazole during pregnancy with the frequency of abnormalities among infants of women exposed to H2-receptor antagonists or other controls. A population based retrospective cohort epidemiological study from the Swedish Medical Birth Registry, covering approximately 99% of pregnancies, from 1995 to 99, reported on 955 infants (824 exposed during the first trimester with 39 of these exposed beyond first trimester, and 131 exposed after the first trimester) whose mothers used omeprazole during pregnancy. The number of infants exposed in utero to omeprazole that had any malformation, low birth weight, low Apgar score, or hospitalization was similar to the number observed in this population. The number of infants born with ventricular septal defects and the number of stillborn infants was slightly higher in the omeprazole-exposed infants than the expected number in this population. A population-based retrospective cohort study covering all live births in Denmark from 1996 to 2009, reported on 1,800 live births whose mothers used omeprazole during the first trimester of pregnancy and 837,317 live births whose mothers did not use any proton pump inhibitor. The overall rate of birth defects in infants born to mothers with first trimester exposure to omeprazole was 2.9% and 2.6% in infants born to mothers not exposed to any proton pump inhibitor during the first trimester. A retrospective cohort study reported on 689 pregnant women exposed to either H2-blockers or omeprazole in the first trimester (134 exposed to omeprazole) and 1,572 pregnant women unexposed to either during the first trimester. The overall malformation rate in offspring born to mothers with first trimester exposure to omeprazole, an H2-blocker, or were unexposed was 3.6%, 5.5%, and 4.1% respectively. A small prospective observational cohort study followed 113 women exposed to omeprazole during pregnancy (89% with first trimester exposures). The reported rate of major congenital malformations was 4% in the omeprazole group, 2% in controls exposed to non-teratogens, and 2.8% in disease paired controls. Rates of spontaneous and elective abortions, preterm deliveries, gestational age at delivery, and mean birth weight were similar among the groups. Several studies have reported no apparent adverse short-term effects on the infant when single-dose oral or intravenous omeprazole was administered to over 200 pregnant women as premedication for cesarean section under general anesthesia. Animal Data Omeprazole Reproductive studies conducted with omeprazole in rats at oral doses up to 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at doses up to 69.1 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis) during organogenesis did not disclose any evidence for a teratogenic potential of omeprazole. In rabbits, omeprazole in a dose range of 6.9 to 69.1 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis) administered during organogenesis produced dose-related increases in embryo-lethality, fetal resorptions, and pregnancy disruptions. In rats, dose-related embryo/fetal toxicity and postnatal developmental toxicity were observed in offspring resulting from parents treated with omeprazole at 13.8 to 138.0 mg/kg/day (about 3.4 to 34 times an oral human dose of 40 mg on a body surface area basis), administered prior to mating through the lactation period. Esomeprazole No effects on embryo-fetal development were observed in reproduction studies with esomeprazole magnesium in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) or in rabbits at oral doses up to 86 mg/kg/day (about 41 times the human dose on a body surface area basis) administered during organogenesis. A pre- and postnatal developmental toxicity study in rats with additional endpoints to evaluate bone development was performed with esomeprazole magnesium at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). Neonatal/early postnatal (birth to weaning) survival was decreased at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). Body weight and body weight gain were reduced and neurobehavioral or general developmental delays in the immediate post-weaning timeframe were evident at doses equal to or greater than 69 mg/kg/day (about 17 times an oral human dose of 40 mg on a body surface area basis). In addition, decreased femur length, width and thickness of cortical bone, decreased thickness of the tibial growth plate and minimal to mild bone marrow hypocellularity were noted at doses equal to or greater than 14 mg/kg/day (about 3.4 times an oral human dose of 40 mg on a body surface area basis). Physeal dysplasia in the femur was observed in offspring of rats treated with oral doses of esomeprazole magnesium at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). Effects on maternal bone were observed in pregnant and lactating rats in a pre- and postnatal toxicity study when esomeprazole magnesium was administered at oral doses of 14 to 280 mg/kg/day (about 3.4 to 68 times an oral human dose of 40 mg on a body surface area basis). When rats were dosed from gestational day 7 through weaning on postnatal day 21, a statistically significant decrease in maternal femur weight of up to 14% (as compared to placebo treatment) was observed at doses equal to or greater than 138 mg/kg/day (about 34 times an oral human dose of 40 mg on a body surface area basis). A pre- and postnatal development study in rats with esomeprazole strontium (using equimolar doses compared to esomeprazole magnesium study) produced similar results in dams and pups as described above. A follow up developmental toxicity study in rats with further time points to evaluate pup bone development from postnatal day 2 to adulthood was performed with esomeprazole magnesium at oral doses of 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) where esomeprazole administration was from either gestational day 7 or gestational day 16 until parturition. When maternal administration was confined to gestation only, there were no effects on bone physeal morphology in the offspring at any age.

Risk Summary Esomeprazole is the S-isomer of omeprazole and limited data suggest that omeprazole may be present in human milk. There are no clinical data on the effects of esomeprazole on the breastfed infant or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for esomeprazole and any potential adverse effects on the breastfed infant from esomeprazole or from the underlying maternal condition.

The safety and effectiveness of esomeprazole sodium for injection have been established in pediatric patients 1 month to 17 years of age for the short-term treatment of GERD with EE, as an alternative to oral therapy when oral esomeprazole is not possible or appropriate. Use of esomeprazole sodium for injection in this age group is based on extrapolation of adult efficacy to children and the selection of dose based on exposure-matching of pediatrics to adults supported by the following evidence: a) results observed from a pharmacokinetic (PK) study on esomeprazole sodium for injection in pediatric patients, b) predictions from a population PK model comparing I.V. PK data between adult and pediatric patients, and c) relationship between exposure and pharmacodynamic results obtained from adult I.V. and pediatric oral data and d) PK results from adequate and well-controlled studies that supported the approval of esomeprazole sodium for injection in adults [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.1)]. The safety and effectiveness of esomeprazole sodium for injection have not been established in patients less than 1 month of age for the treatment of GERD with EE or for risk reduction of rebleeding of gastric or duodenal ulcer following therapeutic endoscopy. Juvenile Animal Data In a juvenile rat toxicity study, esomeprazole was administered with both magnesium and strontium salts at oral doses about 34 to 68 times a daily human dose of 40 mg based on body surface area. Increases in death were seen at the high dose, and at all doses of esomeprazole, there were decreases in body weight, body weight gain, femur weight and femur length, and decreases in overall growth [see Nonclinical Toxicology (13.2)].

In a clinical trial of patients with bleeding gastric or duodenal ulcers, 52% of 375 patients randomized to esomeprazole sodium for injection were 65 years of age and over. No overall differences in safety and efficacy were observed between the elderly and younger individuals, and other reported clinical experience with esomeprazole sodium for injection and oral esomeprazole has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

GERD with EE Exposure to esomeprazole was increased substantially in patients with severe hepatic impairment (Child-Pugh Class C) but not in patients with mild to moderate hepatic impairment (Child-Pugh Classes A and B) compared to patients with normal liver function [see Clinical Pharmacology (12.3)]. For adult patients, no dosage adjustment is necessary for mild to moderate hepatic impairment. For patients with severe hepatic impairment the maximum recommended dosage is 20 mg once daily [see Dosage and Administration (2.3)]. Risk Reduction of Rebleeding of Gastric or Duodenal Ulcers following Therapeutic Endoscopy There are no pharmacokinetic data available for esomeprazole sodium for injection administered as continuous intravenous administration in patients with hepatic impairment. Exposure to intravenous omeprazole, of which esomeprazole is an enantiomer, increased in patients with all degrees of hepatic impairment compared to subjects with normal liver function [see Clinical Pharmacology (12.3)]. For adult patients, no dosage adjustment of the initial esomeprazole sodium for injection 80 mg loading dose is necessary for patients with any degree of hepatic impairment. Reduce the rate of the continuous infusion to 6 mg/hour for patients with mild to moderate liver impairment (Child-Pugh Classes A and B) and to 4 mg/hour for patients with severe hepatic impairment (Child-Pugh Class C) [see Dosage and Administration (2.3)].

The symptoms described in connection with deliberate esomeprazole overdose (limited experience of doses in excess of 240 mg/day) are transient. Reports of overdosage with omeprazole in humans may also be relevant. Doses ranged up to 2,400 mg (120 times the usual recommended clinical dose). Manifestations were variable, but included confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for oral omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive. If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage.

{ "type": "p", "children": [], "text": "The symptoms described in connection with deliberate esomeprazole overdose (limited experience of doses in excess of 240 mg/day) are transient. Reports of overdosage with omeprazole in humans may also be relevant. Doses ranged up to 2,400 mg (120 times the usual recommended clinical dose). Manifestations were variable, but included confusion, drowsiness, blurred vision, tachycardia, nausea, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen at recommended dosages. See the full prescribing information for oral omeprazole for complete safety information. No specific antidote for esomeprazole is known. Since esomeprazole is extensively protein bound, it is not expected to be removed by dialysis. In the event of overdosage, treatment should be symptomatic and supportive.\n If over-exposure occurs, call your Poison Control Center at 1-800-222-1222 for current information on the management of poisoning or overdosage." }

The active ingredient in esomeprazole sodium for injection is (S)-5-methoxy-2[[(4-methoxy-3,5-dimethyl-2-pyridinyl)-methyl]sulfinyl]-1 H-benzimidazole sodium, a PPI. Esomeprazole is the S-isomer of omeprazole, which is a mixture of the S- and R-isomers. Its molecular formula is C17H18N3O3SNa with molecular weight of 367.4 g/mol (sodium salt) and 345.4 g/mol (parent compound). Esomeprazole sodium is a white or almost white, hygroscopic powder. It is very soluble in water and freely soluble in ethanol (95%). The structural formula is: 

{ "type": "p", "children": [], "text": "The active ingredient in esomeprazole sodium for injection is (S)-5-methoxy-2[[(4-methoxy-3,5-dimethyl-2-pyridinyl)-methyl]sulfinyl]-1 H-benzimidazole sodium, a PPI. Esomeprazole is the S-isomer of omeprazole, which is a mixture of the S- and R-isomers. Its molecular formula is C17H18N3O3SNa with molecular weight of 367.4 g/mol (sodium salt) and 345.4 g/mol (parent compound). Esomeprazole sodium is a white or almost white, hygroscopic powder. It is very soluble in water and freely soluble in ethanol (95%). The structural formula is:  " }

Esomeprazole sodium for injection is supplied as a sterile, freeze-dried, white to off-white, porous cake or powder in a 5 mL single-dose vial, intended for intravenous administration after reconstitution with 0.9% Sodium Chloride Injection, USP; Lactated Ringer’s Injection, USP or 5% Dextrose Injection, USP. Esomeprazole sodium for injection contains 40 mg esomeprazole (equivalent to 42.5 mg esomeprazole sodium), edetate disodium 1.5 mg and sodium hydroxide q.s. for pH adjustment. The pH of reconstituted solution of esomeprazole sodium for injection depends on the reconstitution volume and is in the pH range of 9 to 11. The stability of esomeprazole sodium in aqueous solution is strongly pH dependent. The rate of degradation increases with decreasing pH.

{ "type": "p", "children": [], "text": "Esomeprazole sodium for injection is supplied as a sterile, freeze-dried, white to off-white, porous cake or powder in a 5 mL single-dose vial, intended for intravenous administration after reconstitution with 0.9% Sodium Chloride Injection, USP; Lactated Ringer’s Injection, USP or 5% Dextrose Injection, USP. Esomeprazole sodium for injection contains 40 mg esomeprazole (equivalent to 42.5 mg esomeprazole sodium), edetate disodium 1.5 mg and sodium hydroxide q.s. for pH adjustment. The pH of reconstituted solution of esomeprazole sodium for injection depends on the reconstitution volume and is in the pH range of 9 to 11. The stability of esomeprazole sodium in aqueous solution is strongly pH dependent. The rate of degradation increases with decreasing pH." }

Esomeprazole belongs to a class of antisecretory compounds, the substituted benzimidazoles, that suppress gastric acid secretion by specific inhibition of the H+/K+ ATPase enzyme system at the secretory surface of the gastric parietal cell. Esomeprazole is protonated and converted in the acidic compartment of the parietal cell forming the active inhibitor, the achiral sulphenamide. Because this enzyme system is regarded as the acid (proton) pump within the gastric mucosa, esomeprazole has been characterized as a gastric acid-pump inhibitor, in that it blocks the final step of acid production. This effect is dose-related and leads to inhibition of both basal and stimulated acid secretion irrespective of the stimulus.

Antisecretory Activity

The effect of esomeprazole on 24-hour intragastric pH in healthy subjects was evaluated in two studies of 20 mg and 40 mg esomeprazole sodium for injection infused intravenously once daily over 30 minutes for 5 days, as shown in Table 7.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 7: Effect of Esomeprazole Sodium for Injection on Intragastric pH on Day 5      </span> </caption> <colgroup> <col width="32.94%"/> <col width="34.1%"/> <col width="32.94%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="justify" class="Lrule Rrule" valign="top"></td><td align="center" class="Rrule" valign="top"><span class="Bold"> Esomeprazole sodium for injection</span> <br/> <span class="Bold">20 mg once daily</span> <br/> <span class="Bold">(n=22) </span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold"> Esomeprazole sodium for injection</span> <br/> <span class="Bold">40 mg once daily</span> <br/> <span class="Bold">(n=38) </span> <br/> </td> </tr> <tr class="Last"> <td class="Lrule Rrule" valign="middle">% Time Gastric pH&gt;4<span class="Bold"></span> <br/>(95% CI)<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="middle">49.5<span class="Bold"></span> <br/>41.9 to 57.2<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="middle">66.2<span class="Bold"></span> <br/>62.4 to 70.0<span class="Bold"></span> <br/> </td> </tr> </tbody> </table></div>

Gastric pH was measured over a 24-hour period The effects of esomeprazole on 24-hour intragastric pH following administration of an intravenous infusion of 80 mg esomeprazole sodium for injection over 30 minutes followed by a continuous infusion of 8 mg/hour for 23.5 hours was evaluated in two studies. In H. pylori-negative healthy Caucasian subjects (n=24), the % time over 24 hours (95% CI) when the intragastric pH was > 6 and > 7 was 52.3 % (40.3, 64.4) and 4.8 % (1.8, 7.8), respectively. In H. pylori-positive (n=8) and H. pylori-negative (n=11) healthy Chinese subjects, the % time over 24 hours (95% CI) when intragastric pH was > 6 and > 7 was 53% (45.6, 60.3) and 15.1% (9.5, 20.7). The percentage of time with intragastric pH > 6 [59% vs. 47%] and with pH > 7 [17% vs. 11%] tended to be larger in the H. pylori positive subjects compared to H. pylori-negative subjects. Serum Gastrin Effects The effect of esomeprazole on serum gastrin concentrations was evaluated in approximately 2,700 patients in clinical trials of oral esomeprazole for up to 8 weeks and in over 1,300 patients treated for up to 12 months. The mean fasting gastrin level increased in a dose-related manner. The increase in serum gastrin concentrations reached a plateau within two to three months of therapy and returned to baseline levels within four weeks after discontinuation of therapy. Increased gastrin causes enterochromaffin-like cell hyperplasia and increased serum Chromogranin A (CgA) levels. The increased CgA levels may cause false positive results in diagnostic investigations for neuroendocrine tumors [see Warnings and Precautions (5.9)]. Enterochromaffin-like (ECL) Cell Effects There are no data available on the effects of intravenous esomeprazole on ECL cells. Human gastric biopsy specimens have been obtained from more than 3,000 patients (both children and adults) treated orally with omeprazole in long-term clinical trials. The incidence of ECL cell hyperplasia in these studies increased with time; however, no case of ECL cell carcinoids, dysplasia, or neoplasia has been found in these patients [see Nonclinical Toxicology (13.1)]. In over 1,000 patients treated with oral esomeprazole (10 mg, 20 mg or 40 mg/day) for up to 12 months, the prevalence of ECL cell hyperplasia increased with time and dose. No patient developed ECL cell carcinoids, dysplasia, or neoplasia in the gastric mucosa. Endocrine Effects Esomeprazole had no effect on thyroid function when given in oral doses of 20 mg or 40 mg for 4 weeks. Other effects of esomeprazole on the endocrine system were assessed in studies of omeprazole. Oral doses of omeprazole 30 mg or 40 mg per day for 2 to 4 weeks had no effect on carbohydrate metabolism, circulating levels of parathyroid hormone, cortisol, estradiol, testosterone, prolactin, cholecystokinin or secretin.

Absorption The pharmacokinetics of esomeprazole in healthy subjects following administration of esomeprazole sodium for injection 20 mg and 40 mg once daily as intravenous infusion over 30 minutes for 5 days are shown in Table 8.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 8: Geometric Mean (95% CI) Pharmacokinetic Parameters of Esomeprazole Sodium for Injection Following Dosing for 5 Days   </span> </caption> <colgroup> <col width="25.96%"/> <col width="41.08%"/> <col width="32.94%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="left" class="Lrule Rrule" valign="top"> <br/> <span class="Bold">                             <br/> <br/>Parameter</span></td><td align="center" class="Rrule" valign="top"><span class="Bold"> Esomeprazole sodium for injection</span> <br/> <span class="Bold">20 mg</span> <br/> <span class="Bold">(n=24) </span> <br/> </td><td align="center" class="Rrule" valign="top"><span class="Bold">Esomeprazole sodium for injection</span> <br/> <span class="Bold">40 mg</span> <br/> <span class="Bold">(n=38) </span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">AUC (micromol*h/L)<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="top">5.1<br/>(4.0:6.6)<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="top">16.2<br/>(14.5:18.2)<span class="Bold"></span> <br/> </td> </tr> <tr class="Botrule"> <td align="justify" class="Lrule Rrule" valign="top">C<span class="Sub">max</span> (micromol/L))<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="top">3.9<br/>(3.2:4.7)<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="top">7.5<br/>(6.9:8.1)<span class="Bold"></span> <br/> </td> </tr> <tr class="Last"> <td align="justify" class="Lrule Rrule" valign="top">t<span class="Sub">1/2 </span>(h)<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="top">1.1<br/>(0.9:1.2)<span class="Bold"></span> <br/> </td><td align="center" class="Rrule" valign="top">1.4<br/>(1.3:1.5)<span class="Bold"></span> <br/> </td> </tr> </tbody> </table></div>

Following intravenous administration of esomeprazole sodium for injection in 24 healthy subjects as a loading dose of 80 mg over 30 minutes followed by a continuous infusion of 8 mg/hour for 23.5 hours (for a total of 24 hours), esomeprazole pharmacokinetic parameters [geometric mean value (95% CI)] were as follows: AUCt 111.1 micromol*h/L (100.5, 122.7 micromol*h/L), Cmax 15.0 micromol/L (13.5, 16.6 micromol/L), and steady state plasma concentration (Css) 3.9 micromol/L (3.5, 4.5 micromol/L). In another study of healthy Caucasian subjects administered the same treatment regimen. Esomeprazole is a time-dependent inhibitor of CYP2C19, resulting in autoinhibition and nonlinear pharmacokinetics. The systemic exposure increases in a more than dose proportional manner after multiple oral doses of esomeprazole. Compared to the first dose, the systemic exposure (Cmax and AUC0-24h) at steady state following once a day dosing increased by 43% and 90%, respectively, compared to after the first dose for the 20 mg dose and increased by 95% and 159%, respectively, for the 40 mg dose. Distribution Esomeprazole is 97% bound to plasma proteins. Plasma protein binding is constant over the concentration range of 2 to 20 micromol/L. The apparent volume of distribution at steady state in healthy subjects is approximately 16 L. Elimination Metabolism Esomeprazole is extensively metabolized in the liver by the cytochrome P450 (CYP) enzyme system. The metabolites of esomeprazole lack antisecretory activity. The major part of esomeprazole’s metabolism is dependent upon the CYP2C19 isoenzyme, which forms the hydroxy and desmethyl metabolites. The remaining amount is dependent on CYP3A4 which forms the sulphone metabolite. Excretion Esomeprazole is excreted as metabolites primarily in urine but also in feces. Less than 1% of parent drug is excreted in the urine. Esomeprazole is completely eliminated from plasma, and there is no accumulation during once daily administration. The plasma elimination half-life of esomeprazole following intravenous administration of esomeprazole sodium for injection is approximately 1.1 to 1.4 hours and is prolonged with increasing doses. The plasma clearance (CL) is approximately 5.9 to 7.2 L/h during administration of esomeprazole sodium for injection as an intravenous infusion of 80 mg over 30 minutes followed by a continuous infusion of 8 mg/hour for 23.5 hours. Specific Populations Geriatric Patients The AUC and Cmax values of esomeprazole were slightly higher (25% and 18%, respectively) in the elderly as compared to younger subjects at steady state. This increase in exposure is not considered clinically relevant. Pediatric Patients The pharmacokinetics of esomeprazole were evaluated in 50 pediatric patients birth to 17 years of age, inclusive (of which 44 pediatric patients were 1 month to 17 years) in a randomized, open-label, multi-national, multiple dose study of 20 mg esomeprazole sodium for injection administered as a once-daily 3-minute intravenous injection. Esomeprazole plasma AUC values were 183% and 60% higher in pediatric patients aged 6 to 11 years and 12 to 17 years, respectively, compared to adults. Subsequent pharmacokinetic analyses predicted the following dosage regimens would achieve comparable steady-state plasma exposures (AUC0-24) to those observed in adult patients administered 20 mg of esomeprazole sodium for injection once daily: 0.5 mg/kg once daily for pediatric patients 1 month to 11 months of age, 10 mg once daily for pediatric patients 1 year to 17 years with body weight less than 55 kg, and 20 mg once daily for pediatric patients 1 year to 17 years with body weight of 55 kg and greater. Increasing the infusion duration from 3 minutes to 10 minutes or 30 minutes was predicted to produce steady-state Cmax values that were comparable to those observed in adult patients at the 40 mg and 20 mg esomeprazole sodium for injection doses, respectively [see Use in Specific Populations (8.4)]. Male and Female Patients The AUC and Cmax values of esomeprazole were slightly higher (13%) in females than in males at steady state when dosed orally. Similar differences have been seen for intravenous administration of esomeprazole. This increase in exposure is not considered clinically relevant. Patients with Renal Impairment The pharmacokinetics of esomeprazole in patients with renal impairment are not expected to be altered relative to healthy subjects as less than 1% of esomeprazole is excreted unchanged in urine. Patients with Hepatic Impairment The steady state pharmacokinetics of esomeprazole obtained after administration of 40 mg orally once daily to 4 patients each with mild (Child-Pugh Class A), moderate (Child-Pugh Class B), and severe (Child-Pugh Class C) hepatic impairment were compared to those obtained in 36 male and female GERD patients with normal liver function. In patients with mild and moderate hepatic impairment, the AUCs were within the range that could be expected in patients with normal liver function. In patients with severe hepatic impairment, the AUCs were 2 to 3 times higher than in the patients with normal liver function [see Use in Specific Populations (8.6)]. There are no pharmacokinetic data available for esomeprazole administered as continuous intravenous administration in patients with liver impairment. The pharmacokinetics of intravenous omeprazole 80 mg infused over 30 minutes, followed by 8 mg/hour over 47.5 hours in patients with mild (Child-Pugh Class A; n=5), moderate (Child-Pugh Class B; n=4) and severe (Child-Pugh Class C; n=3) liver impairment were compared to those obtained in 24 male and female healthy subjects. In patients with mild and moderate liver impairment, omeprazole clearance and steady state plasma concentration was approximately 35% lower and 50% higher, respectively, than in healthy subjects. In patients with severe liver impairment, the omeprazole clearance was 50% of that in healthy subjects and the steady state plasma concentration was double that in healthy subjects [see Use in Specific Populations (8.6)]. Drug Interaction Studies Effect of Esomeprazole/Omeprazole on Other Drugs In vitro and in vivo studies have shown that esomeprazole is not likely to inhibit CYPs 1A2, 2A6, 2C9, 2D6, 2E1 and 3A4. Antiretrovirals For some antiretroviral drugs, such as rilpivirine, atazanavir and nelfinavir, decreased serum concentrations have been reported when given together with omeprazole [see Drug Interactions (7)]. Rilpivirine: Following multiple doses of rilpivirine (150 mg, daily) and omeprazole (20 mg, daily), AUC was decreased by 40%, Cmax by 40%, and Cmin by 33% for rilpivirine [see Contraindications (4)]. Nelfinavir: Following multiple doses of nelfinavir (1,250 mg, twice daily) and omeprazole (40 mg daily), AUC was decreased by 36% and 92%, Cmax by 37% and 89% and Cmin by 39% and 75% respectively for nelfinavir and M8. Atazanavir: Following multiple doses of atazanavir (400 mg, daily) and omeprazole (40 mg, daily, 2 hours before atazanavir), AUC was decreased by 94%, Cmax by 96%, and Cmin by 95%. Saquinavir: Following multiple dosing of saquinavir/ritonavir (1,000/100 mg) twice daily for 15 days with omeprazole 40 mg daily co-administered days 11 to 15. The AUC was increased by 82%, Cmax by 75%, and Cmin by 106%. The mechanism behind this interaction is not fully elucidated. Clopidogrel In a crossover study, healthy subjects were administered clopidogrel (300 mg loading dose followed by 75 mg per day as the maintenance dosage for 28 days) alone and with esomeprazole (40 mg orally once daily at the same time as clopidogrel) for 29 days. Exposure to the active metabolite of clopidogrel was reduced by 35% to 40% over this time period when clopidogrel and esomeprazole were administered together. Pharmacodynamic parameters were also measured and demonstrated that the change in inhibition of platelet aggregation was related to the change in the exposure to clopidogrel active metabolite [see Warnings and Precautions (5.7), Drug Interactions (7)]. Mycophenolate Mofetil Administration of omeprazole 20 mg twice daily for 4 days and a single 1,000 mg dose of MMF approximately one hour after the last dose of omeprazole to 12 healthy subjects in a cross-over study resulted in a 52% reduction in the Cmax and 23% reduction in the AUC of MPA [see Drug Interactions (7)]. Cilostazol Omeprazole acts as an inhibitor of CYP2C19. Omeprazole, given in doses of 40 mg daily for one week to 20 healthy subjects in cross-over study, increased Cmax and AUC of cilostazol by 18% and 26% respectively. The Cmax and AUC of one of the active metabolites, 3,4-dihydro-cilostazol, which has 4 to 7 times the activity of cilostazol, were increased by 29% and 69%, respectively. Co-administration of cilostazol with omeprazole is expected to increase concentrations of cilostazol and the above mentioned active metabolite [see Drug Interactions (7)]. Diazepam Co-administration of esomeprazole 30 mg and diazepam, a CYP2C19 substrate, resulted in a 45% decrease in clearance of diazepam. Increased plasma levels of diazepam were observed 12 hours after dosing and onwards. However, at that time, the plasma levels of diazepam were below the therapeutic interval, and thus this interaction is unlikely to be of clinical relevance. Digoxin Concomitant administration of omeprazole 20 mg once daily and digoxin in healthy subjects increased the bioavailability of digoxin by 10% (30% in two subjects) [see Drug Interactions (7)]. Other Drugs Concomitant administration of esomeprazole and either naproxen (non-selective NSAID) did not identify any clinically relevant changes in the pharmacokinetic profiles of these NSAIDs. Effect of Other Drugs on Esomeprazole/Omeprazole St. John’s Wort In a cross-over study in 12 healthy male subjects, St. John’s Wort (300 mg three times daily for 14 days) significantly decreased the systemic exposure of omeprazole in CYP2C19 poor metabolizers (Cmax and AUC decreased by 37.5% and 37.9%, respectively) and extensive metabolizers (Cmax and AUC decreased by 49.6% and 43.9%, respectively) [see Drug Interactions (7)]. Voriconazole Concomitant administration of omeprazole and voriconazole (a combined inhibitor of CYP2C19 and CYP3A4) resulted in more than doubling of the omeprazole exposure. When voriconazole (400 mg every 12 hours for one day, followed by 200 mg once daily for 6 days) was given with omeprazole (40 mg once daily for 7 days) to healthy subjects, the steady-state Cmax and AUC0-24 of omeprazole significantly increased: an average of 2 times (90% CI: 1.8, 2.6) and 4 times (90% CI: 3.3, 4.4), respectively, as compared to when omeprazole was given without voriconazole [see Drug Interactions (7)]. Other Drugs Co-administration of esomeprazole with oral contraceptives, diazepam, phenytoin, quinidine, naproxen (non-selective NSAID) did not seem to change the pharmacokinetic profile of esomeprazole.

Effects on Gastrointestinal Microbial Ecology Decreased gastric acidity due to any means including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and, in hospitalized patients, possibly also Clostridium difficile.

CYP2C19, a polymorphic enzyme, is involved in the metabolism of esomeprazole. The CYP2C19*1 allele is fully functional while the CYP2C19*2 and *3 alleles are nonfunctional. There are other alleles associated with no or reduced enzymatic function. Patients carrying two fully functional alleles are extensive metabolizers and those carrying two loss-of-function alleles are poor metabolizers. The systemic exposure to esomeprazole varies with a patient’s metabolism status: poor metabolizers > intermediate metabolizers > extensive metabolizers. Approximately 3% of Caucasians and 15 to 20% of Asians are CYP2C19 poor metabolizers. Systemic esomeprazole exposures were modestly higher (approximately 17%) in CYP2C19 intermediate metabolizers (IM; n=6) compared to extensive metabolizers (EM; n=17) of CYP2C19. Similar pharmacokinetic differences were noted across these genotypes in a study of Chinese healthy subjects that included 7 EMs and 11 IMs. There is very limited pharmacokinetic information for poor metabolizers (PM) from these studies. At steady state following once daily administration of esomeprazole sodium for injection, 40 mg, the ratio of AUC in Poor Metabolizers to AUC in the rest of the population (EMs) is approximately 1.5. This change in exposure is not considered clinically meaningful.

The carcinogenic potential of esomeprazole was assessed using omeprazole studies. In two 24-month oral carcinogenicity studies in rats, omeprazole at daily doses of 1.7, 3.4, 13.8, 44.0, and 140.8 mg/kg/day (about 0.4 to 34 times the human dose of 40 mg/day expressed on a body surface area basis) produced gastric ECL cell carcinoids in a dose-related manner in both male and female rats; the incidence of this effect was markedly higher in female rats, which had higher blood levels of omeprazole. Gastric carcinoids seldom occur in the untreated rat. In addition, ECL cell hyperplasia was present in all treated groups of both sexes. In one of these studies, female rats were treated with 13.8 mg omeprazole/kg/day (about 3.4 times the human dose of 40 mg/day on a body surface area basis) for 1 year, then followed for an additional year without the drug. No carcinoids were seen in these rats. An increased incidence of treatment-related ECL cell hyperplasia was observed at the end of 1 year (94% treated vs 10% controls). By the second year the difference between treated and control rats was much smaller (46% vs 26%) but still showed more hyperplasia in the treated group. Gastric adenocarcinoma was seen in one rat (2%). No similar tumor was seen in male or female rats treated for 2 years. For this strain of rat no similar tumor has been noted historically, but a finding involving only one tumor is difficult to interpret. A 78-week oral mouse carcinogenicity study of omeprazole did not show increased tumor occurrence, but the study was not conclusive. Esomeprazole was negative in the Ames mutation test, in the in vivo rat bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test. Esomeprazole, however, was positive in the in vitro human lymphocyte chromosome aberration test. Omeprazole was positive in the in vitro human lymphocyte chromosome aberration test, the in vivo mouse bone marrow cell chromosome aberration test, and the in vivo mouse micronucleus test. The potential effects of esomeprazole on fertility and reproductive performance were assessed using omeprazole studies. Omeprazole at oral doses up to 138 mg/kg/day in rats (about 34 times the human dose of 40 mg/day on a body surface area basis) was found to have no effect on reproductive performance of parental animals.

Reproduction Studies Reproduction studies have been performed in rats at oral doses up to 280 mg/kg/day (about 68 times an oral human dose of 40 mg on a body surface area basis) and in rabbits at oral doses up to 86 mg/kg/day (about 42 times an oral human dose of 40 mg on a body surface area basis) and have revealed no evidence of impaired fertility or harm to the fetus due to esomeprazole [see Use in Specific Populations (8.1)]. Juvenile Animal Study A 28-day toxicity study with a 14-day recovery phase was conducted in juvenile rats with esomeprazole magnesium at doses of 70 to 280 mg/kg/day (about 17 to 68 times a daily oral human dose of 40 mg on a body surface area basis). An increase in the number of deaths at the high dose of 280 mg/kg/day was observed when juvenile rats were administered esomeprazole magnesium from postnatal day 7 through postnatal day 35. In addition, doses equal to or greater than 140 mg/kg/day (about 34 times a daily oral human dose of 40 mg on a body surface area basis), produced treatment-related decreases in body weight (approximately 14%) and body weight gain, decreases in femur weight and femur length, and affected overall growth. Comparable findings described above have also been observed in this study with another esomeprazole salt, esomeprazole strontium, at equimolar doses of esomeprazole.

Four multicenter, open-label, two-period crossover studies were conducted to compare the pharmacodynamic effects of esomeprazole following intravenous or oral administration on acid suppression in 206 patients with symptoms of GERD with or without erosive esophagitis. Patients were randomized to receive either 20 or 40 mg of esomeprazole sodium for injection or oral esomeprazole once daily for 10 days (Period 1), and then were switched in Period 2 to the other formulation for 10 days, matching their respective dose from Period 1. Esomeprazole sodium for injection, 20 mg and 40 mg was administered as a 3-minute injection in two of the studies and as a 15-minute infusion in the other two studies. The patient population ranged from 18 to 72 years old; 54% were female; 53% Caucasian, 24% Black, 5% Asian, and 17% other race. Basal acid output (BAO) and maximal acid output (MAO) were determined 22 to 24 hours post-dose on Period 1, Day 11; on Period 2, Day 3; and on Period 2, Day 11. BAO and MAO were estimated from 1-hour continuous collections of gastric contents prior to and following (respectively) subcutaneous injection of 6.0 mcg/kg of pentagastrin. In these studies, after 10 days of once daily administration, esomeprazole sodium for injection, 20 mg and 40 mg were similar to the corresponding oral dosage of esomeprazole in their ability to suppress BAO and MAO in these GERD patients (see Table 9 below). There were no major changes in acid suppression when switching between intravenous and oral dosage forms.

<div class="scrollingtable"><table border="0" cellpadding="0" cellspacing="0" width="100%"> <caption> <span>Table 9: Mean (SD) BAO and MAO Measured 22 to 24 Hours Post-Dose Following Once Daily Oral and Intravenous Administration of Esomeprazole for 10 days in GERD Patients with or without a History of EE     </span> </caption> <colgroup> <col width="11.54%"/> <col width="8.66%"/> <col width="21.16%"/> <col width="15.38%"/> <col width="13.46%"/> <col width="15.38%"/> <col width="14.42%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First"> <td align="center" class="Lrule Rrule" rowspan="2" valign="middle"><span class="Bold">Study</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">Dose</span> <br/> <span class="Bold">in mg</span> <br/> </td><td align="center" class="Rrule" rowspan="2" valign="middle"><span class="Bold">Intravenous</span> <br/> <span class="Bold">Administration</span> <br/> <span class="Bold">Method</span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">BAO in mmol H<span class="Sup">+</span>/h</span> <br/> </td><td align="center" class="Rrule" colspan="2" valign="middle"><span class="Bold">MAO in mmol H<span class="Sup">+</span>/h</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle"><span class="Bold">Intravenous</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Oral</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Intravenous</span> <br/> </td><td align="center" class="Rrule" valign="middle"><span class="Bold">Oral</span> <br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">1 (N=42)<br/> </td><td align="center" class="Rrule" valign="middle">20<br/> </td><td align="center" class="Rrule" valign="middle">3-minute injection<br/> </td><td align="center" class="Rrule" valign="middle">0.71 (1.24)<br/> </td><td align="center" class="Rrule" valign="middle">0.69 (1.24)<br/> </td><td align="center" class="Rrule" valign="middle">5.96 (5.41)<br/> </td><td align="center" class="Rrule" valign="middle">5.27 (5.39)<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">2 (N=44)<br/> </td><td align="center" class="Rrule" valign="middle">20<br/> </td><td align="center" class="Rrule" valign="middle">15-minute infusion<br/> </td><td align="center" class="Rrule" valign="middle">0.78 (1.38)<br/> </td><td align="center" class="Rrule" valign="middle">0.82 (1.34)<br/> </td><td align="center" class="Rrule" valign="middle">5.95 (4.00)<br/> </td><td align="center" class="Rrule" valign="middle">5.26 (4.12)<br/> </td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule" valign="middle">3 (N=50)<br/> </td><td align="center" class="Rrule" valign="middle">40<br/> </td><td align="center" class="Rrule" valign="middle">3-minute injection<br/> </td><td align="center" class="Rrule" valign="middle">0.36 (0.61)<br/> </td><td align="center" class="Rrule" valign="middle">0.31 (0.55)<br/> </td><td align="center" class="Rrule" valign="middle">5.06 (3.90)<br/> </td><td align="center" class="Rrule" valign="middle">4.41 (3.11)<br/> </td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule" valign="middle">4 (N=47)<br/> </td><td align="center" class="Rrule" valign="middle">40<br/> </td><td align="center" class="Rrule" valign="middle">15-minute infusion<br/> </td><td align="center" class="Rrule" valign="middle">0.36 (0.79)<br/> </td><td align="center" class="Rrule" valign="middle">0.22 (0.39)<br/> </td><td align="center" class="Rrule" valign="middle">4.74 (3.65)<br/> </td><td align="center" class="Rrule" valign="middle">3.52 (2.86)<br/> </td> </tr> </tbody> </table></div>

A randomized, double blind, placebo-controlled clinical study was conducted in 764 patients who presented with endoscopically confirmed gastric or duodenal ulcer bleeding. The population was 18 to 98 years old; 68% were male, 87% Caucasian, 1% Black, 7% Asian, and 4% other race. Following endoscopic hemostasis, patients were randomized to either placebo or esomeprazole sodium for injection, 80 mg as an intravenous infusion over 30 minutes followed by a continuous infusion of 8 mg/hour for a total of 72 hours. After the initial 72­-hour period, all patients received an oral PPI for 27 days. The occurrence of rebleeding within 3 days of randomization was 5.9% in the esomeprazole sodium for injection treated group compared to 10.3% for the placebo group (treatment difference -4.4%; 95% confidence interval: -8.3%, -0.6%; p=0.03). This treatment difference was similar to that observed at Day 7 and Day 30, during which all patients were receiving an oral PPI. A randomized, double blind, placebo-controlled single-center study conducted in Hong Kong also demonstrated a reduction compared to placebo in the risk of rebleeding within 72 hours in patients with bleeding gastric or duodenal ulcers who received racemic omeprazole, 50% of which is the S-enantiomer esomeprazole.

Esomeprazole sodium for injection is supplied as a sterile, freeze-dried, white to off-white, porous cake or powder containing 40 mg of esomeprazole per single-dose vial. 40 mg per vial: Single-Dose Vials in a Carton of 10 (each vial contains 40 mg of esomeprazole)                                                                NDC 55150-185-05 Storage Store at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature]. Protect from light. Store in carton until time of use. Following reconstitution and administration, discard any unused portion of esomeprazole solution [see Dosage and Administration (2.4, 2.5)]. The vial stopper is not made with natural rubber latex.

{ "type": "p", "children": [], "text": "Esomeprazole sodium for injection is supplied as a sterile, freeze-dried, white to off-white, porous cake or powder containing 40 mg of esomeprazole per single-dose vial.\n\n 40 mg per vial:\n\n Single-Dose Vials in a Carton of 10 (each vial contains 40 mg of esomeprazole)                                                                NDC 55150-185-05\n\n\nStorage\n\n\n Store at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature]. Protect from light. Store in carton until time of use.\n Following reconstitution and administration, discard any unused portion of esomeprazole solution [see Dosage and Administration (2.4, 2.5)].\n The vial stopper is not made with natural rubber latex." }

Adverse Reactions Advise patients to report to their healthcare provider if they experience any signs or symptoms consistent with:

{ "type": "p", "children": [], "text": "\nAdverse Reactions\n\n Advise patients to report to their healthcare provider if they experience any signs or symptoms consistent with:" }

{ "type": "ul", "children": [ "Hypersensitivity Reactions [see Contraindications (4)] \n", "Acute Tubulointerstitial Nephritis [see Warnings and Precautions (5.2)] \n", "\nClostridium difficile-Associated Diarrhea [see Warnings and Precautions (5.3)] \n", "Bone Fracture [see Warnings and Precautions (5.4)] \n", "Severe Cutaneous Adverse Reactions [see Warnings and Precautions (5.5)]\n", "Cutaneous and Systemic Lupus Erythematosus [see Warnings and Precautions (5.6)] \n", "Hypomagnesemia and Mineral Metabolism [see Warnings and Precautions (5.8)] \n" ], "text": "" }

Drug Interactions Advise patients to report to their healthcare provider before they start treatment with any of the following: 

{ "type": "p", "children": [], "text": "\nDrug Interactions\n\n Advise patients to report to their healthcare provider before they start treatment with any of the following: " }

{ "type": "ul", "children": [ "Rilpivirine-containing products [see Contraindications (4)]\n", "Clopidogrel [see Warnings and Precautions (5.7)]\n", "St. John’s Wort or rifampin [see Warnings and Precautions (5.9)] \n", "High-dose methotrexate [see Warnings and Precautions (5.11)]\n" ], "text": "" }

Administration

{ "type": "p", "children": [], "text": "\nAdministration\n" }

{ "type": "ul", "children": [ "Inform patients that antacids may be used while taking esomeprazole sodium for injection." ], "text": "" }

Distributed by: Eugia US LLC 279 Princeton-Hightstown Rd.E. Windsor, NJ 08520 Manufactured by: Eugia Pharma Specialities Limited Hyderabad – 500032India

{ "type": "p", "children": [], "text": "Distributed by:\nEugia US LLC\n279 Princeton-Hightstown Rd.E. Windsor, NJ 08520\n Manufactured by:\nEugia Pharma Specialities Limited\nHyderabad – 500032India" }

Rx only                 NDC 55150-185-05 Esomeprazole Sodium for Injection 40 mg per vial* For Intravenous Use Only. Discard unused portion. Sterile             Single-Dose Vial

{ "type": "p", "children": [], "text": "\nRx only                 NDC 55150-185-05\nEsomeprazole Sodium for Injection\n40 mg per vial*\nFor Intravenous Use Only. Discard unused portion.\nSterile             Single-Dose Vial\n\n" }

Rx only                                        NDC 55150-185-05 Esomeprazole Sodium for Injection 40 mg per vial* For Intravenous Use Only.Discard unused portion. Sterile                                   10 Single-Dose Vials eugia

{ "type": "p", "children": [], "text": "\nRx only                                        NDC 55150-185-05\nEsomeprazole Sodium for Injection\n40 mg per vial*\nFor Intravenous Use Only.Discard unused portion.\nSterile                                   10 Single-Dose Vials eugia\n\n" }